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1 An Aging World: 2008 International Population Reports Issued June 2009 P95/09-1 By Kevin Kinsella and Wan He U.S. Department of Health and Human Services National Institutes of Health NATIONAL INSTITUTE ON AGING U.S. Department of Commerce Economics and Statistics Administration U.S. CENSUS BUREAU

2 Acknowledgments This report was prepared by Kevin Kinsella and Wan He under the general direction of Peter O. Way, Chief, International Programs Center, Population Division, U.S. Census Bureau. Research for and production of this report were supported under an interagency agreement with the Behavioral and Social Research Program, National Institute on Aging, Agreement No. Y1-AG For their review of and substantive suggestions regarding this report, the authors are grateful to Richard V. Burkhauser, College of Human Ecology, Cornell University; Emily Grundy, Centre for Population Studies, London School of Hygiene and Tropical Medicine; Marjorie Hanson, Data Integration Division, U.S. Census Bureau; Rebecca Hoop and Kimball T. Jonas, Demographic Statistical Methods Division, U.S. Census Bureau; Enrique J. Lamas, Chief, Population Division, U.S. Census Bureau; Richard M. Suzman, Director, Behavioral and Social Research Program, National Institute on Aging; and Peter O. Way, Chief, International Programs Center, Population Division, U.S. Census Bureau. The authors are especially grateful to Frank B. Hobbs, Population Division, U.S. Census Bureau, for his thorough review and insightful comments. Within the Census Bureau s Population Division, Mitali Sen and Robert M. Leddy, Jr. provided mapping assistance for the report. Mitali Sen also contributed analysis and text concerning the pension system in India and Internet use among older people. Mary Beth Kennedy was instrumental in the completion of myriad tasks involving data verification, table and graph production, and general report preparation. The authors also thank Census Bureau summer intern Nathaniel Lewis, who assisted with various aspects of the report. Janet Sweeney and Jamie Stark of the Census Bureau s Administrative and Customer Services Division, Francis Grailand Hall, Chief, provided publication and printing management, graphics design and composition, and editorial review for print and electronic media. General direction and production management were provided by Claudette E. Bennett, Assistant Division Chief, and Wanda Cevis, Chief, Publications Services Branch. Thanks also are due to Peter D. Johnson, Population Division, U.S. Census Bureau, who oversees the International Data Base; and to Lorraine Wright, U.S. Census Bureau Library, International Collection, who handled the acquisition of a multitude of source materials used in this report.

5 20 Questions About Global Aging See what you know about worldwide population aging in the early twenty-first century. Answers appear on next page. 1. True or false? The world s chil- United States will be at least True or false? Sex ratios at older dren under age 5 outnumber of age by the year ages (i.e., the number of older people aged 65 and over. men per 100 older women) usu- 8. True or false? The number of ally are 90 or greater. 2. The world s older population the world s oldest old (people (65 and over) is increasing 80 and over) is growing more 15. In developed countries, recent by approximately how many rapidly than the older (65 and increases in labor force participation people each month in 2008? over) population as a whole. rates of older workers a. 75,000 are due to changing work pat- 9. Japan has the highest life b. 350,000 terns of: expectancy among the major c. 600,000 a. Men countries of the world. How b. Women d. 870,000 many can a Japanese c. Men and women 3. Which of the world s developlive, on average? 16. What proportion of the world s baby born in 2008 expect to ing regions has the highest a. 70 countries have a public old-age percentage of older people? b. 75 security program? a. Africa c. 82 a. All b. Latin America d. 90 b. Three-fourths c. The Caribbean c. One-half d. Asia 10. True or false? Today, aver- d. One-fourth age life expectancy at birth 4. China has the world s largest is less than 45 in some 17. True or false? In most coun- total population (more than countries. tries, international migration 1.3 billion). Which country has little effect on the overall has the world s largest older 11. What are the leading killers population age structure. population? of older people in Europe and 18. In which country are older a. China North America? people least likely to live alone? b. Germany a. Cancers a. The Philippines c. Russia b. Circulatory diseases b. Hungary d. India c. Respiratory diseases c. Canada d. Accidents 5. True or false? More than half d. Denmark of the world s older people live 12. True or false? The percentage 19. True or false? In developing in the industrialized nations of of older people in rural areas countries, older men are more Europe, North America, Japan, is generally lower than in large likely than older women to be and Australia. cities. illiterate. 6. Which country has the world s 13. There are more older widows 20. True or false? In any country, highest percentage of older than widowers in virtually all it is almost impossible to have people in 2008? countries because: population aging and a decline a. Sweden a. Women live longer than in total population size at the men. b. Japan same time. b. Women typically c. Spain marry men older than d. Italy themselves. 7. True or false? Current demo- c. Men are more likely to graphic projections suggest that remarry after divorce or 35 percent of all people in the the death of a spouse. d. All of the above. iii An Aging World: 2008 U.S. Census Bureau

6 Answers 1. True. Although the world s 8. True. The oldest old are the rates of older men in most develpopulation is aging, children fastest-growing component oped countries were declining, still outnumber older people as of many national populations. whereas those for women were of Projections indicate, The world s growth rate for the often increasing. More recently, however, that in fewer than and-over population from activity rates for men also have, older people will out to 2008 was 4.3 percent, begun to increase. number children for the first while that of the world=s older 16. b. As of 2004, 167 countries/ time in history. (65 and over) population as a areas of the world (74 percent) whole was 2.1 percent (com- 2. d. The estimated change in the reported having some form pared with 1.2 percent for the total size of the world=s older of an old age/disability/survitotal [all ages] population). population between July 2007 vors program. In many cases, and July 2008 was more than 9. c. 82, up from about 52 in program coverage is limited to 10.4 million people, an average certain occupational subgroups. of 870,000 each month. 10. True. In some African countries 17. True. International migration 3. c. The Caribbean, with 7.8 per- (e.g., Malawi, South Africa, does not play a major role cent of all people aged 65 and Zambia, and Zimbabwe) where in the aging process of most over in Corresponding the HIV/AIDS epidemic is par- countries, but it can be imporfigures for other regions are ticularly devastating, average tant in small populations that Latin America, 6.4 percent; Asia life expectancy at birth is less have experienced a combination (excluding Japan), 6.2 percent; than 45. of emigration of working-aged and Africa, 3.3 percent. adults, immigration of older 11. b. Circulatory diseases (esperetirees from other countries, 4. a. China also has the largest cially heart disease and stroke) and/or return migration of forolder population, numbering typically are the leading cause mer emigrants. 106 million in of death as reported by the World Health Organization. In 18. a. The Philippines. The percent- 5. False. Although industrialized the United States in 2004, heart age of older people living alone nations have higher percentdisease was the leading cause in developing countries is usually ages of older people than do of death in the 65-and-over age much lower than that in develmost developing countries, 62 group, accounting for 30 percent oped countries; levels in the latter percent of all people aged 65 of all deaths. This percentage, may exceed 40 percent. and over now live in the develhowever, has declined in recent oping countries of Africa, Asia, 19. False. Older women are less decades (it was 44 percent in the Latin America, the Caribbean, likely to be literate. For exam- United States in 1980). and Oceania. ple, data from China s False. Rural-to-urban migration census revealed that 26 percent 6. b. Japan, with 22 percent of its tends to lower the percentage of older women could read and population aged 65 or over, has of younger adults in rural areas write, compared with 66 perrecently supplanted Italy as the and correspondingly raise the cent of older men. world s oldest major country. percentage of older residents. 20. False. Total population size in at 7. False. Although the United 13. d. All of the above. least 11 countries is projected to States will age rapidly when decline from today s levels by at the Baby Boomers (people born 14. False. Sex ratios at older ages are least 1 million people by 2050; between 1946 and 1964) begin 90 or above in about 20 percent in some countries (e.g., Japan, to reach age 65 after the year of the world s countries/areas. Russia, and the Ukraine) the 2010, the percentage of the Sex ratios at older ages are 80 or decline has already begun. All of population aged 65 and over in below in a majority of countries/ these nations are aging, and the the year 2050 is projected to be areas and 50 or below in parts of combination of population aging 20 percent (compared with 12 the former Soviet Union. and population decline is historipercent today). 15. c. From the late 1960s until the cally unprecedented. 1990s, labor force participation iv An Aging World: 2008 U.S. Census Bureau

7 Table of Contents 20 Questions About Global Aging... iii Chapter 1. Introduction... 1 Chapter 2. Global Aging... 7 Older People to Soon Outnumber Young Children... 7 World s Older Population Increasing 870,000 Each Month... 7 Older Population Growing Fastest in Developing Countries Europe Still the "Oldest" World Region, Sub-Saharan Africa the "Youngest" Japan Now the World s "Oldest" Major Country Singapore s Older Population to More Than Triple by Parts of Asia Aging the Fastest An Aging Index Median Age to Rise in All Countries Chapter 3. The Dynamics of Population Aging Legacy of Fertility Decline Aging and Population Decline: An Unprecedented Development Is Below-Replacement Fertility Here to Stay? Older Populations Themselves Often Are Aging Researchers Eye Increase in Centenarians Older People More Likely Than Others to Live in Rural Areas No Clear Trend Toward Disproportionate Aging of Large Cities Chapter 4. Life Expectancy and Mortality Life Expectancy at Birth Exceeds 80 Years in 11 Countries Twentieth Century Life Expectancy Doubled in Some Developed Countries Rising Life Expectancy at Birth Is Not Universal Highest Recorded Average Life Expectancy Continues to Rise Female Advantage in Life Expectancy at Birth Nearly Universal Female Mortality Advantage Persists in Older Age Old-Age Mortality Rates Declining Over Time Cardiovascular Disease the Preeminent Cause of Death Among Older People Persistent Concern About Lung Cancer Chapter 5. Health and Disability Epidemiological Transition Shifts the Survival Curve Developing-Country Transition Most Apparent in Latin America Is a Longer Life a Better Life? Crossnational Assessment of Health Expectancy Remains Elusive Prevalence of Chronic Conditions Is Increasing While Disability Is Decreasing in Developed Countries... 54

8 Female Advantage in Life Expectancy Partially Offset by Disability Disability Prevalence Is Likely to Increase in Developing Countries Burden of Noncommunicable Disease Is Growing Obesity May Threaten Improvements in Life Expectancy Early-Life Conditions Affect Adult Health Does Population Aging Impact Health System Solvency? Chapter 6. Gender Balance, Marital Status, and Living Arrangements Older Population Sex Ratios Very Low in Eastern Europe Older Men Are Married; Older Women Are Widowed Widowhood Rises Sharply After Age Most Older People Reside With Family Intergenerational Coresidence Is on the Decline Nearly Half of Older Women Live Alone in Some European Nations Skipped-Generation Households Are a Feature of Sub-Saharan Africa Use of Long-Term Care Facilities Varies by Social Group Chapter 7. Social and Family Support Some Countries Have Just Three Working-Aged People per One Older Person Elements of the Total Dependency Ratio Reflect Age Structure and Support Needs China s Shifting Age Composition Alters Dependency Ratios Adult Children Are the Main Providers of Support to Older People Proportions of Childless Older People May Rise in the Future Home Help Services Reduce the Need for Institutionalization Older People Provide As Well As Receive Support Grandparenting Is a Primary Role in Many Nations Chapter 8. Education and Literacy Attainment Gap Between Developed and Developing Regions Illiteracy at Older Ages Still Common in Developing Countries Future Older People Will Have Higher Levels of Literacy and Education Educational Disadvantage Common in Rural Areas Educational Level Correlates With Older People s Employment and Earnings Education Improves Older People s Physical Functioning and Self-Reported Health Health Literacy and Financial Literacy Are Gaining Attention Chapter 9. Labor Force Participation and Retirement Labor Force Participation at Ages 65 and Over Exceeds 30 Percent in Some Countries New Trend in Labor Force Participation Since Agriculture Still an Important Source of Employment for Older People Different Bridges to Retirement Have Emerged Part-Time Work Increases With Age Unemployment Relatively Low Among Older Workers Invalidity and Disability Programs May Be Avenues to Retirement Actual Retirement Age Often Lower Than Statutory Age Adults Spending Greater Portion of Life in Retirement Public Pension System Provisions Can Induce Early Retirement Developed Country Trend Toward Earlier Retirement Has Changed Chapter 10. Pensions and Old-Age Security Demographic Change Alone May Double the Retiree/Worker Ratio Number of National Old-Age Security Systems Rising Pension Coverage Spotty and Declining in Developing Countries

9 From Defined Benefit to Defined Contribution How Generous Are Public Pensions? Public Pensions Absorb One-Eighth of GDP in the European Union Mandatory Private Pension Plans Becoming More Prominent Administrative Costs of Pension Systems High in Some Developing Countries Private Pension Fund Assets a Major Source of Long-Term Capital Trend Toward Pension Privatization Began in Chile Universal Pensions Address Aging and Poverty Governments Considering New Pillars of Old-Age Security Chapter 11. Concluding Remarks Appendix A. Country Composition of World Regions Appendix B. Detailed Tables Appendix C. Sources and Limitations of the Data Appendix D. References FIGuRES 1-1. Percent Population Aged 65 and Over: Percent Population Aged 65 and Over: Young Children and Older People as a Percentage of Global Population: 1950 to Population Aged 65 and Over by Size Threshold (2 Million): 2008 and Average Annual Percent Growth of Older Population in Developed and Developing Countries: 1950 to The World s 25 Oldest Countries: Percent Increase in Population Aged 65 and Over: 2008 to The Speed of Population Aging in Selected Countries Aging Index: 2008 and Aging Index for Counties in China: Median Age in 12 Countries: 2008, 2020, and Population in Developed and Developing Countries by Age and Sex: 1960, 2000, and Total Fertility Rate for Selected Countries by Region: Countries/Areas With a Projected Population Decline of at Least 1 Million Between 2008 and Projected Age-Specific Population Change in Russia Between 2008 and Global Distribution of People Aged 80 and Over: Oldest Old as a Percentage of All Older People: 2008 and Percent Change in the World s Population: 2005 to Economic Life Cycle of a Typical Thai Worker Life Expectancy at Birth for Selected Countries by Region: Life Expectancy at Birth: Life Expectancy at Birth for Four Countries by Sex: 1950 to Population With and Without HIV/AIDS-Related Mortality in Botswana by Age and Sex: 2006 and Highest National Life Expectancy at Birth: 1840 to Female Advantage in Life Expectancy at Birth for Selected Countries: Mortality Rates at Older Ages for Three Countries by Sex: Evolution of Life Expectancy at Age 65 in Japan, the United States, and France by Sex: 1950 to

10 4-9. Percent Change in Death Rates for Two Older Age Groups in Selected Countries by Sex: 1994 to Major Causes of Death in the European Union by Age: Lifetime Risk of Lung Cancer in 13 European Countries by Sex: Circa Survival Curve for U.S. White Females: 1901 and Proportion of All Deaths Occurring at Age 65 or Over in 29 Countries/Areas: Circa Chronic Disability Decline in the United States: 1982 to Age and Sex Structure of Disability in the Philippines: The Increasing Burden of Chronic Noncommunicable Diseases on Countries by Income Level: 2002 and Percent Overweight and Obese Among Men and Women Aged 50 and Over in Ten European Countries: Probability of Being Disabled at Ages 60 and Over Conditional on Early Childhood Health Conditions in Seven Latin American/Caribbean Cities and in Puerto Rico: Circa Health Expenditure and Percent Aged 65 and Over in 24 OECD Nations: Components of Real Growth in Health Care Spending per Capita, United States and 20-Nation OECD Aggregate: 1970 to Sex Ratio of the Older Population: Aggregate Sex Ratios for Older Age Groups: 2008 and Percent Married at Older Ages for Selected Countries by Sex: Circa Percent Widowed in Denmark by Age and Sex: Change in Proportions Married and Widowed for People Aged 65 and Over in the United Kingdom by Sex: 1971 to Living Arrangements for Household Population Aged 65 and Over in Argentina: Living Arrangements for People Aged 65 and Over in Japan: 1960 to People Aged 65 and Over Living Alone in Ten European Nations by Sex: Living Arrangements for People Aged 60 and Over in Sub-Saharan Africa by Residence: Circa Percentage of People Aged 65 and Over in Institutions: Circa Older Dependency Ratio for 20 Countries: Older Dependency Ratio: Older Dependency Ratio for World Regions: 2000, 2020, and Standard and Alternative Older Dependency Ratios for Five Countries: Composition of Total Dependency Ratios for Selected Countries: Population for China by Single Year of Age and Sex: Youth and Older Dependency Ratios in China: 1953 to Proximity to Nearest Living Child for People Aged 80 and Over in Ten European Countries: Percent Childless Among Women Aged 65 in Selected Countries: Percentage of Population Aged 65 and Over Receiving Formal Home Help in Selected Countries: Circa Percentage of People Aged 55 to 64 Who Have Completed Secondary and Tertiary Education in 29 OECD Countries: Percentage of People in Two Age Groups Who Have Completed Secondary Education in Nine Developing Countries by Sex: Circa Percent Illiterate for Two Age Groups in Four Countries by Sex: Circa Percentage of People Aged 55 and Over Who Have Completed High School or Above in the United States: 1940 to Percent Literate by Age, Sex, and Urban and Rural Residence in India: Employment Rate for People Aged 50 to 64 in Germany, Bulgaria, and the United Kingdom by Education Level:

11 8-7. Relative Earnings for People Aged 25 to 64 in 11 Countries by Educational Attainment: Percentage of People Aged 60 and Over With Activity Limitations in China by Educational Attainment and Urban/Rural Residence: Internet Use in the United Kingdom by Age: April Labor Force Participation Rates for Italy, New Zealand, Pakistan, and Madagascar by Age and Sex: Aggregate European Union Employment Rate for People Aged 55 to 64: 1994 to Labor Force Participation Rate for People Aged 55 to 64 in Six Latin American Countries by Sex: Mid-/Late 1990s and Circa Employment for People Aged 65 and Over in Ireland by Sector and Sex: People Aged 65 and Over as a Percentage of All Small Agricultural Unit Holders in Nine Countries: Percentage of All Workers Who Work Part-Time in the European Union by Age and Sex: Number of Working Hours per Week for Employed Older Workers in the European Union by Age and Sex: Older Workers Not Working Because of Illness or Disability in 20 Countries: Official Versus Actual Average Retirement Age for Seven Countries by Sex: Years of Life Expectancy After Retirement in Ten Countries by Sex: 2004 Versus Ratio of Retirement-Aged to Working-Aged Population for Ten Countries by Sex: 2005 and Countries With Public Old-Age/Disability/Survivors Programs: 1940 to Social Security Coverage in 13 Latin American Countries: Circa Net Replacement Rate in Mandatory Pension Programs for Men in Selected Countries: Pension Expenditure in Selected European Union Countries as a Percentage of GDP: Administrative Costs as a Percentage of Assets in Privately Managed Plans for Selected Countries: Private Pension Fund Assets as a Percentage of GDP in Six Countries: 1970 and Real Rate of Return of Chile s Private Pension System: 1981 to China s Declining Ratio of Covered Workers to Pensioners: 1980 to Percentage of Households With Members Aged 50 and Over Owning Mutual Funds and Stocks for Ten Countries: TABLES 2-1. Percent Older Population by Region: 2008 to Rank Order of the World s 25 Largest Older Populations: Percent Population Aged 65 and Over for 20 Cities Compared With the Respective National Average: Selected Years, 1999 to Life Expectancy at Birth for Selected Countries by Sex: 1900, 1950, and Suicide Rates for Selected Age Groups in 30 Countries: Circa Rank Order of the Ten Leading Causes of Death in Taiwan: 1956, 1976, 1996, and Average Annual Growth Rate in the Prevalence of Selected Conditions Among People Aged 65 and Over: Selected Periods, 1980 to Rank Order of Disease Burden in High-Income Versus Low- and Middle-Income Countries: Percent of People Aged 60 and Over Living Alone by Sex: Circa

12 6-2. Cumulative Crude Death Rate Due to AIDS and Living Arrangements of People Aged 60 and Over in 22 Sub-Saharan African Countries: Circa Total, Older, and Youth Dependency Ratios for World Regions: Labor Force Participation Rates by Age and Sex for Selected Countries: Circa Countries With Universal Non-Means-Tested Pensions: Circa BOxES 1-1. Geographic Terms in This Report Projected Data in This Report Numbers and Percentages Demographic Transition Theory and the Age-Sex Composition of Populations Demographic Dividends Demographic Impact of HIV/AIDS Suicide Rates Much Higher Among Older Men Than Women Disability Decline in the United States Socioeconomic Correlates of Mortality and Disability Middle-Aged Britons Are Notably Healthier Than Middle-Aged Americans Standard and Alternative Older Dependency Ratios Silver Surfers Older People and the Internet India s National Old Age Pension Scheme China Rethinking Social Security in an Emerging Market Economy New Data for an Aging World APPEnDIx TABLES B-1. Total Population, Percent Older, and Percent Oldest Old by Country: 1950, 1980, 2010, and B-2. Percent Change in Population for Older Age Groups by Country: 2000 to 2020 and 2020 to B-3. Median Age by Country: 2000, 2020, and B-4. Sex Ratio for Population 35 Years and Over by Age and Country: 2000, 2020, and B-5. Total and Older Urban Population by Sex and Country: Selected Years 1969 to B-6. Marital Status of the Older Population by Sex, Country, and Age: Selected Years 1969 to B-7. Dependency Ratios by Country: 2000, 2020, and B-8. Labor Force Participation Rates by Sex, Age, and Country: Selected Years 1969 to

13 ChApTer 1. Introduction The world s population is now but increasingly, the result of Some populations are aging aging at an unprecedented rate. reduced death rates at older ages. while their size declines. While Fertility decline together with the world s population is aging, Population aging and its global urbanization were the dominant total population size is simulimplications have received considglobal demographic trends during taneously declining in some erable attention in industrialized the second half of the twentieth countries, and the list of these countries, and awareness is growing century, much as rapid improve- countries is projected to expand. in the rest of the world. In 2002, the ments in life expectancy charac- United Nations convened its sec- Noncommunicable diseases are terized the early 1900s. As we ond World Assembly on Aging (the move through the first decade of becoming a growing burden. first was in 1982) to consider the the twenty-first century, popularamifications of global population Chronic noncommunicable dis- tion aging has emerged as a major eases are now the major cause demographic worldwide trend. aging. In 2007, the U.S. National of death among older people in Declining fertility and improved Institute on Aging and the U.S. both developed and developing health and longevity have gener- Department of State jointly issued countries. ated rising numbers and propora report entitled Why Population Aging Matters. Using data from Family structures are changing. tions of the older population in the U.S. Census Bureau, the United As people live longer and have most of the world. As education Nations, the Statistical Office of the fewer children, family strucand income levels rise, increasing European Communities, as well as tures are transformed and care numbers of individuals reach older from regional surveys and scientific options in older age may change. age with markedly different longevity and personal expectations than journals, the report identified nine Patterns of work and retirement their forebears. trends that offer a snapshot are shifting. Shrinking ratios of challenges: Population aging represents, in of workers to pensioners and one sense, a human success story The world s population is aging. people spending a larger por- of increased longevity. However, People aged 65 and over will tion of their lives in retirement the steady, sustained growth of soon outnumber children under increasingly tax existing health older populations also poses many age 5 for the first time in history. and pension systems. challenges to policymakers. 1 In a Life expectancy is increasing. Social insurance systems are few time, just after 2010, the Most countries show a steady evolving. As social insurance numbers and proportions of older increase in longevity over time, expenditures escalate, an people (especially the oldest old) which raises questions about the increasing number of countries will begin to rise rapidly in most potential for the human lifespan. are evaluating the sustainability developed and many developing of these systems and revamping countries. The increase is primar- The number of the oldest old is old-age security provisions. ily the result of high fertility levels rising. The world s population after World War II and secondarily, aged 80 and over is projected to New economic challenges are 1 This report generally uses the follow- increase 233 percent between emerging. Population aging has ing terms for component age groups: the 2008 and 2040, compared with and will have large effects on older population to refer to people aged 160 percent for the popula- 65 and over and the oldest old to refer to social entitlement programs, people 80 and over. In some contexts (e.g., tion aged 65 and over and 33 labor supply, and total savings older people in the labor force), it is useful percent for the total population or necessary (due to data restrictions) to use around the globe. other age groupings. of all ages. U.S. Census Bureau An Aging World:

14 Each of the nine trends is examined further in this report. Rigorous scientific research on global aging issues based on comparable harmonized data will help nations better address the challenges and opportunities of an aging world (Burkhauser and Lillard, 2005). The growth of older populations has commonly been associated with the developed, industrialized countries of Europe and North America. Most developed nations are among the demographically oldest in the world today, and some may have more grandparents than young children before the middle of the twenty-first century. In the early 1990s, developed nations as a whole had about as many children under 15 of age as people aged 55 and over (approximately 22 percent of the total population in each category). The developing world, by contrast, still had a high proportion of children (35 percent of all people were under age 15) and a relatively low proportion (10 percent) of people aged 55 and over. However, the numbers of older people in developing nations often are large and everywhere are increasing. Well over half of the world s people aged 65 and over now live in developing nations (62 percent, or 313 million people, in 2008). By 2040, this share is projected to exceed three-quarters, with the absolute number of older people in developing countries topping 1 billion. Many developing countries have had or are now experiencing a notable downturn in their rate of natural population increase (births minus deaths), similar to what previously occurred in most industrialized nations. As this process accelerates, age structures will change. Eventually, older people become an ever-larger proportion of each nation s total population. Box 1-1. Geographic Terms in This Report The developed and developing country categories used in this report correspond directly to the more developed and less developed classification employed by the United Nations. Developed countries comprise all nations in Europe (including some nations that formerly were part of the Soviet Union) and North America, plus Japan, Australia, and New Zealand. The remaining nations of the world are classified as developing countries. Data for world regions (e.g., Latin America and the Caribbean) generally are aggregated from individual country files of the International Data Base (IDB) of the Population Division of the Census Bureau. See Appendix A for a list of countries in each region. Data for China include the Special Administrative Regions of Hong Kong and Macau. Data for China do not include Taiwan. One purpose of this report, then, by disaggregating statistics into is to look at past, current, and narrower age groups where posprojected numbers, proportions, sible. Such examination may reveal and growth rates of older popula- important demographic, social, tions. Older populations also have and economic differences that have increased because of worldwide direct bearing on social policy now improvements in health services, and in the future. For example, educational status, and economic the fastest-growing portion of the development. The characteristics older population in many nations is of older people are likely to be the oldest old, those aged 80 and increasingly heterogeneous within over. Rapidly expanding numbers nations. A second purpose of An of very old people represent a Aging World: 2008 is to summarize social phenomenon without historisocioeconomic statistics for both cal precedent one that is bound developed and developing nations. to alter previously held stereo- Comparable data are included for types. The growth of the oldest old as many as 52 nations when the cat- is salient to public policy because egories are reasonably consistent. individual needs and social respon- In 2008, these 52 nations (Appendix sibilities change considerably with Table B-1) contained 77 percent of increased age. the world s total population and are An Aging World: 2008 is the ninth referred to as study countries at crossnational report in a Census various points in the text. Bureau series on the world s older This report focuses primarily on populations. The first two reports, people 65 old and older. An Aging World (1987) and Aging in As is true of younger age groups, the Third World (1988), used data people aged 65 and over have primarily from the 1970 and 1980 very different economic resources, rounds of worldwide censuses health statuses, living arrange- (those taken from 1965 to 1974 ments, and levels of integration and 1975 to 1984, respectively), as into social life. An Aging World: well as demographic projections 2008 acknowledges this diversity produced by the United Nations 2 An Aging World: 2008 U.S. Census Bureau

15 Box 1-2. Projected Data in This Report Throughout this report, projections of population size and composition come from the Population Division of the Census Bureau, unless otherwise indicated. As discussed further in Appendix C, these projections are based on analyses of individual national population age and sex structures; components of population change (rates of fertility, mortality, and net migration); and assumptions about the future trajectories of fertility, mortality, and migration for each country. The population projections in this report were current as of January Projections for the United States and other countries are updated periodically as new data become available. Therefore, the data in this report are not the latest available for every country and, by extension, for groups of countries aggregated into regions. The impact of projection updates on indicators of population aging generally is modest and does not affect the overall trends described in this report. Interested users may find the latest population figures for the United States (released in August 2008) at <www.census.gov/population /www/projections/index.html>. The latest population projections for all other countries of the world are available at <www.census.gov /ipc/www/idb/>. Appendix C provides more infor- mation about the sources, limita- tions, and availability of IDB files and report data in general. There are vast differences in both the quantity and quality of statistics reported by various countries. The United Nations and other organizations have provided international recommendations for the standard- ization of concepts and defini- tions of data collected in censuses Population Division from its 1984 assessment of global population. Subsequent reports Population and Health Transitions (1992); Aging in Eastern Europe and the Former Soviet Union (1993); An Aging World II (1993); Older Workers, Retirement and Pensions (1995); An Aging World: 2001; Population Aging in Sub-Saharan Africa: Demographic Dimensions 2006 and the current report include historical data from the earlier reports, available data from the 1990 and 2000 rounds of censuses, information from national sample surveys and administrative records, historical and projected data from the United Nations, and data from component population projections prepared by the International Programs Center (IPC) of the Population Division of the Census Bureau. Differences among reports in projected data reflect either a change in the source of the projections or revised demographic insights and assumptions based on the most recent information. Many of the data included in this report are from the Census Bureau s International Data Base (IDB). The IDB is maintained and updated by the IPC and is funded in part by the Behavioral and Social Research Program of the U.S. National Institute on Aging. IDB contents are readily available from the Census Bureau s Web site; the direct access address is <www.census.gov/ipc /www/idb/>. and surveys. Nevertheless, wide discrepancies still exist in data collection and tabulation practices because of differences in the resources and information needs among countries. As a result, any attempt to compile standardized data across countries requires consideration of whether and how the reported data should be analyzed to achieve comparability. This caveat is particularly applicable to the present report because the IDB data are not accompanied by standard errors. Accordingly, no conclusions can be reached concerning the statistical significance of differences between population estimates presented in this report. The demographic data in this report have been evaluated by Census Bureau analysts and are believed to be representative of the situation in a given country. The data are internally consistent and congruent with other facts known about the nations. These demographic data also have been checked for external consistency, that is, compared with information on other countries in the same region or subregion and with countries elsewhere at approximately the same level of socioeconomic development. The socioeconomic data, by contrast, typically are as reported by the countries themselves. Although Census Bureau analysts have not directly evaluated these data, analysts have attempted to resolve discrepancies in reported figures and eliminate international inconsistencies; data with obvious incongruities are not included. People are living longer and, in some parts of the world, healthier lives. This represents one of the crowning achievements of the last century but also a significant challenge as proportions of older people increase in most countries. U.S. Census Bureau An Aging World:

16 4 An Aging World: 2008 U.S. Census Bureau Percent 65 and over Less than to to or more Figure 1-1. Percent Population Aged 65 and Over: 2008 Source: U.S. Census Bureau, International Data Base, accessed on May 27, 2008.

17 U.S. Census Bureau An Aging World: Percent 65 and over Less than to to or more Figure 1-2. Percent Population Aged 65 and Over: 2040 Source: U.S. Census Bureau, International Data Base, accessed on May 27, 2008.

18 Current growth of older popula- need to understand the charac- interrelated perspectives, including tions is steady in some countries teristics of older populations, demographic, social, economic, and explosive in others. As the their strengths, and their require- medical, biological, and genetic. World War II Baby Boom cohorts ments. The effects will be felt not The IDB and this report are an common to many countries begin just within individual nations but effort to contribute to a consistent, to reach older age after 2010, there throughout the global economy. systematic, quantitative compariwill be a jump in the proportion Understanding the dynamics of son of older populations in various of the world s older population aging requires accurate descrip- countries. (Figures 1-1 and 1-2). Policymakers tions of older populations from 6 An Aging World: 2008 U.S. Census Bureau

19 ChApTer 2. Global Aging The current level and pace of OLDER PEOPLE TO SOOn WORLD S OLDER population aging vary widely by OuTnuMBER YOunG POPuLATIOn InCREASInG geographic region, and usually CHILDREn 870,000 EACH MOnTH within regions as well, but virtually Estimates of the world s popula- The world s older population has all nations are now experiencing tion age structure at various points been growing for centuries. What growth in their number of older in the past indicate that children is new is the accelerating pace of residents. While developed nations under age 5 have outnumbered aging. The world s older populahave relatively high proportions of older people. In fewer than 10 tion of 506 million people in 2008 people aged 65 and over, the most from now this will change (U.S. represented an increase of 10.4 rapid increases in older population National Institute on Aging and U.S. million since The world s are in the developing world. Even Department of State, 2007). For the older population grew by an averin nations where the older percentfirst time, people aged 65 and over age of 870,000 people each month age of the total population remains during the year. Projections 10 small, absolute numbers may be are expected to outnumber children hence suggest that the annual net rising steeply. Everywhere, the under age 5 (Figure 2-1). The global increase will be on the order of 23 growth of older populations poses population aged 65 and over was million, an average net monthly challenges to social institutions estimated to be 506 million as of gain of 1.9 million people. In 1990, that must adapt to changing midyear 2008, about 7 percent of 26 nations had older populations of age structures. the world s population. By 2040, at least 2 million, and by 2008, 38 the world is projected to have 1.3 countries had reached the 2-million billion older people accounting for mark. Projections to the year percent of the total. U.S. Census Bureau An Aging World:

20 Figure 2-1. Young Children and Older People as a Percentage of Global Population: 1950 to Percent 15 Under and over Source: United Nations Department of Economic and Social Affairs, 2007b. indicate that 72 countries will have about the future course of of the world s future older popula- 2 million or more people aged 65 human fertility. Short-term and tion, human mortality is the key and over (Figure 2-2). medium-term projections of tomor- demographic component. However, row s older population are not con- uncertainties about changing mor- Projections of older populations tingent upon fertility because any- tality may lead to widely divergent may be more accurate than projecone who will be aged 65 or over in projections of the size of tomortions of total population, which 2040 has already been born. When row s older population. must incorporate assumptions projecting the size and composition 8 An Aging World: 2008 U.S. Census Bureau

21 U.S. Census Bureau An Aging World: Population 65 and over Under 2 million in 2008 and million or more in 2008 and million or more in 2040, not in 2008 Figure 2-2. Population Aged 65 and Over by Size Threshold (2 Million): 2008 and 2040 Source: U.S. Census Bureau, International Data Base, accessed on May 27, 2008.

22 Figure 2-3. Average Annual Percent Growth of Older Population in Developed and Developing Countries: 1950 to Percent growth 4 65-and-over population in developing countries 3 65-and-over population in developed countries 2 1 Total world population, all ages Note: Based on average 5-year period growth rates. Source: United Nations Department of Economic and Social Affairs, 2007b. OLDER POPuLATIOn countries. Most notable in devel- The current aggregate growth rate GROWInG FASTEST In oped countries is the steep plunge of the older population in develop- DEvELOPInG COunTRIES in growth in the early 1980s. The ing countries is more than double slowing of the growth rate may that in developed countries and Population aging has become a be attributed largely to the low also double that of the total world widely known phenomenon in the birth rates that prevailed in many population. The rate in developing industrialized nations of Europe and developed countries during and countries began to rise in the early Northern America, but developing after World War I, combined with 1960s and has generally contincountries are aging as well, often at war deaths and the effects of the ued to increase until recent. a much faster rate than in the develinfluenza pandemic of After a brief downturn related oped world. Eighty-one percent A second, less severe, decline in to lower fertility during World War (702,000 people) of the world s net the rate of growth began in the II the older growth rate in develgain of older individuals from July mid-1990s and continued in the oping countries is expected to 2007 to July 2008 occurred in develearly 2000s. This decline corre- rise beyond and remain above 3.5 oping countries. As of 2008, 62 sponds to lowered fertility during percent annually from 2015 through percent (313 million) of the world s the Great Depression and World 2030 before declining in subsepeople aged 65 and over lived in War II. These drops in the growth quent decades. By 2040, today s developing countries. rate highlight the important influ- developing countries are likely to Figure 2-3 shows the different pat- ence that past fertility trends have be home to more than 1 billion peoterns of growth for older popula- on current and projected changes ple aged 65 and over, 76 percent of tions in developed and developing in the size of older populations. the projected world total. 10 An Aging World: 2008 U.S. Census Bureau

23 EuROPE STILL THE major world regions for many OLDEST WORLD REGIOn, decades, and they should remain SuB-SAHARAn AFRICA THE the global leaders well into the YOunGEST twenty-first century (Table 2-1). 1 Eastern and Western Europe have had the highest population proportions aged 65 and over among By 2040, more than 1 of every 4 1 See Appendix A for a list of countries in each of the regions used in this report. Table 2-1. Percent Older Population by Region: 2008 to 2040 Region 65 and over 75 and over 80 and over Northern Africa Sub-Saharan Africa Asia (excluding Near East) Near East Eastern Europe Western Europe Latin America/Caribbean Northern America Oceania Europeans is likely to be at least 65 of age, and 1 in 7 is likely to be at least 75 old. Northern America and Oceania also have relatively high aggregate older population percentages today, and more than 1 in 5 people in Northern America is projected to be at least age 65 by Levels for 2008 in Northern Africa, Asia, and Latin America/Caribbean are expected to more than double by 2040, while aggregate proportions of the older population in Sub-Saharan Africa will grow rather modestly as a result of continued high fertility and, in some nations, the impact of HIV/AIDS (see Chapter 4). Two important factors bear mention when considering aggregate older proportions of regional populations. The first is that regional averages often hide wide diversity. Bangladesh and Thailand may be close geographically, but these countries have divergent paths of expected population aging. Many Caribbean nations have high older population proportions (the Caribbean is the oldest of all developing world regions) in relation to their Central American neighbors. Second, and more important, percentages by themselves may not give a sense of population momentum. Although the change in the percent aged 65 and over in Sub-Saharan Africa from 2008 to 2020 is barely perceptible, the absolute number of older people is expected to jump by more than 40 percent, from 23.7 million to 33.3 million. Source: U.S. Census Bureau, International Data Base, accessed on March 24, U.S. Census Bureau An Aging World:

24 Figure 2-4. The World s 25 Oldest Countries: 2008 (Percent of population aged 65 and over) Japan Italy Germany Greece Sweden Spain Austria Bulgaria Estonia Belgium Portugal Croatia Latvia Georgia Finland France Slovenia Ukraine United Kingdom Switzerland Lithuania Denmark Hungary Serbia Norway Source: U.S. Census Bureau, International Data Base, accessed on January 28, JAPAn now THE WORLD S major nations. 2 More than twenty- with an older proportion of less OLDEST MAJOR COunTRY one percent of all Japanese are than 13 percent in 2008, is rather aged 65 and over, with levels of young by developed-country stan- The percentage of the population 18 percent to 20 percent seen dards. However, as the large birth aged 65 and over ranged from in Germany, Greece, Italy, and cohorts of the post-world War II 13 percent to 21 percent in 2008 Sweden. With the exception of Baby Boom (people born from 1946 in most developed countries. For Japan and Georgia, the world s 25 through 1964) begin to reach age many, Sweden or Italy had oldest countries are all in Europe 65 after 2010, the percent older in the highest such proportion, but (Figure 2-4). The United States, the United States will rise markrecently Japan became the demoedly likely reaching 20 percent 2 graphically oldest of the world s Some small areas/jurisdictions have high proportions of older residents. In 2008, 22 shortly after the year Still, percent of all residents of the European prin- this figure will be lower than that cipality of Monaco were aged 65 and over. Guernsey, the Isle of Man, and San Marino projected for most countries of also had relatively high proportions (about 17 Western Europe. percent aged 65 and over in each). 12 An Aging World: 2008 U.S. Census Bureau

25 Figure 2-5. Percent Increase in Population Aged 65 and Over: 2008 to 2040 Developed countries Developing countries Singapore Colombia India Malaysia Egypt Costa Rica Bangladesh Kenya Philippines Morocco Mexico Guatemala Peru Brazil Indonesia Tunisia China Pakistan Turkey Uganda South Korea Sri Lanka Thailand Chile Israel Canada New Zealand United States Australia Malawi Argentina Jamaica Norway Poland Czech Republic France United Kingdom Denmark Uruguay Austria Belgium Italy Greece South Africa Hungary Zimbabwe Sweden Germany Russia Japan Ukraine Bulgaria SInGAPORE S OLDER POPuLATIOn TO MORE THAn TRIPLE BY 2040 During the period , the projected increase in the older population in the 52 study countries ranges from 18 percent in Bulgaria to 316 percent in Singapore (Figure 2-5). Today s older nations will experience relatively little change compared with many developing nations. In addition to Bulgaria, the projected increase in the 65-andover population between 2008 and 2040 is less than 50 percent in Germany, Greece, Hungary, Italy, Japan, Russia, Sweden, and Ukraine. In contrast, gains of more than 250 percent are expected in many developing countries. Many of these are in Asia (e.g., Bangladesh, India, Malaysia, and the Philippines), but the list includes Colombia, Costa Rica, Egypt, and Kenya as well. Source: U.S. Census Bureau, International Data Base, accessed on January 17, U.S. Census Bureau An Aging World:

26 Figure 2-6. The Speed of Population Aging in Selected Countries (Number of required or expected for percent of population aged 65 and over to rise from 7 percent to 14 percent) Developed countries Developing countries France ( ) 115 Azerbaijan ( ) 33 Sweden ( ) 85 Chile ( ) 27 Australia ( ) 73 China ( ) 26 United States ( ) 69 Sri Lanka ( ) 24 Canada ( ) 65 Tunisia ( ) 24 Hungary ( ) 53 Thailand ( ) 22 Spain ( ) 45 Brazil ( ) 21 United Kingdom ( ) 45 Colombia ( ) 19 Poland ( ) 45 Singapore ( ) 19 Japan ( ) 26 South Korea ( ) 18 Sources: Kinsella and Gist, 1995; and U.S. Census Bureau, International Data Base, accessed on March 24, PARTS OF ASIA developed-country experience, In response to this compression of AGInG THE FASTEST many developing countries are aging, institutions in developing experiencing (or soon will experi- countries are called upon to adapt Most of today s developed nations ence) a sudden rise in the number quickly to accommodate a new age have had decades to adjust to and percentage of older people, structure. Some nations will be changing age structures. For examoften within a single genera- forced to confront issues, such as ple, it took more than a century for tion. Notably swift increases are social support and the allocation France s population aged 65 and expected in China and elsewhere of resources across generations, over to increase from 7 percent to in eastern and southeastern without the accompanying eco- 14 percent of the total population. Asia, fueled by dramatic drops nomic growth that characterized Rapidly aging Japan is unusual in fertility levels during the last the experience of aging societies in among developed countries; the three decades. The change in the West. An often-heard maxim is percent of the population aged 65 some other developing countries that developed countries grew rich and over in Japan increased from will be equally rapid; the same before they grew old, while many 7 percent to 14 percent in 26 demographic aging process that developing nations may grow old, from 1970 to 1996 (Figure unfolded over more than a century before they grow rich. 2-6). In contrast to the usual in France will likely occur in two decades in Brazil and Colombia. 14 An Aging World: 2008 U.S. Census Bureau

27 Figure 2-7. Aging Index: 2008 and 2040 (Aging index = [65+/0-14]*100) Northern Africa Sub-Saharan Africa Asia (excluding Near East) Near East Eastern Europe Western Europe Latin America/Caribbean Northern America Oceania Source: U.S. Census Bureau, International Data Base, accessed on January 15, An AGInG InDEx however, the proportional rise in countries, reaching 314 in Japan the aging index in developing coun- and 322 in Singapore. An easily understood indicator of tries is expected to be larger than age structure is the aging index, The aging index also is useful for in developed countries. defined here as the number of examining within-country differpeople aged 65 and over per 100 Among the 52 study countries in ences in the level of population youths under age 15. Figure , 10 European countries and aging. As noted in Chapter 3, shows the current and projected Japan had more older people than urban and rural areas may differ aging index by world region. The youth aged 0 to 14. By 2040, all in the extent of aging. There may index presently is highest in Europe developed countries in Figure 2-5 also be other geographic differand lowest in Africa and the Near are projected to have an aging ences, especially in large nations East. Today s aging index typically index of at least 130, with the such as China (Figure 2-8). Based is much lower in developing coun- exception of the United States on 2000 census data, the overtries than in the developed world, (104). The projected aging index all aging index in China was 31. and the pattern of future change is in the United States is lower than However, this measure ranged likely to be more varied. If future in several developing countries, from less than 20 in 510 counties, fertility rates remain relatively among them Chile, China, Sri many of which are in the central high, as expected in Sub-Saharan Lanka, and Uruguay. By 2040, the and western regions, to more than Africa, the absolute change in the aging index is expected to be in 100 in Beijing and Shanghai and aging index will be small. Generally, excess of 200 in ten of the study several surrounding counties. U.S. Census Bureau An Aging World:

28 16 An Aging World: 2008 U.S. Census Bureau Not available Less than to or more Figure 2-8. Aging Index for Counties in China: 2000 Source: China 2000 census data.

29 Figure 2-9. Median Age in 12 Countries: 2008, 2020, and 2040 (In ) Australia Germany Greece Japan United Kingdom United States Brazil China Mexico Pakistan MEDIAn AGE TO RISE In ALL COunTRIES Population aging refers most simply to increasing proportions of older people within an overall population age structure. Another way to think of population aging is to consider a society s median age, the age that divides a population into numerically equal parts of younger and older people. For example, the 2008 median age in the United States was 36, indicating that the number of people under age 36 equals the number who have already celebrated their 36th birthday. The 2008 median ages of the 52 study countries ranged from 15 in Uganda to 44 in Japan. Developed countries are all above the 37-year level, with the exception of New Zealand (35) and the United States (36). A majority of developing nations have median ages under 27. During the next three decades, the median age will increase in all 52 countries, though at different rates. By 2040, Japan is projected to have the highest median age, with half of its population aged 54 and over (Figure 2-9). This is largely a reflection of recent and projected low levels of fertility. In contrast, persistently high birth rates (and in some cases the impact of adult AIDS deaths) are likely to constrain the 2040 median age to less than 30 in Malawi, Uganda, and Zimbabwe (Appendix Table B-3). South Africa Uganda Source: U.S. Census Bureau, International Data Base, accessed on January 17, U.S. Census Bureau An Aging World:

30 Box 2-1. numbers and Percentages Population aging is most commonly measured by the share of all people in a country or region above a certain age; for example, people aged 65 and over as a percentage of all people. Several other indicators of aging also may be used. This report includes measures such as the aging index, median age, the speed of aging, and the dependency ratio. One could also consider indicators such as average life expectancy or the proportion of total life expectancy lived after age 60 or 65. Sometimes overlooked are absolute numbers of older people. While Figure 2-4 shows the world s oldest countries according to the percentage of the population aged 65 and over, Table 2-2 ranks the top 25 countries in terms of the absolute size of the 65-and-over population in Table 2-2. Rank Order of the World s 25 Largest Older Populations: 2008 (In millions) Rank Country Population aged 65 and over 1 China India United States Japan Russia Germany Indonesia Brazil Italy France United Kingdom Ukraine Spain Pakistan Mexico Thailand Bangladesh Poland Turkey Vietnam South Korea Canada Argentina Nigeria Philippines Source: U.S. Census Bureau, International Data Base, accessed on February 19, An Aging World: 2008 U.S. Census Bureau

31 ChApTer 3. The Dynamics of Population Aging The process of population aging adult mortality rates improve. policies (Salt, Clarke, and Wanner has been, in most countries to Successive birth cohorts may even- 2004; and Vignon, 2005). date, determined primarily by fertil- tually become smaller and smaller, Figure 3-1 illustrates the historical ity (birth) rates and secondarily by although countries may experience and projected aggregate populamortality (death) rates. Populations a baby boom echo as women tion age transition in developing with high fertility tend to have low of prior large birth cohorts reach and developed countries. At one proportions of older people and childbearing age. International time, most, if not all, countries had vice versa. Demographers use the migration usually does not play a youthful age structure similar term demographic transition (see a major role in the aging process to that of developing countries Box 3-1) to refer to a gradual pro- but can be important in smaller as a whole in 1960, with a large cess wherein a society moves from populations. Certain Caribbean percentage of the entire populaa situation of relatively high rates nations, for example, have experition under the age of 15. Given of fertility and mortality to one of enced a combination of emigration the relatively high rates of fertility low rates of fertility and mortal- of working-aged adults, immigrathat prevailed in many developing ity. This transition is character- tion of older retirees from other countries in the 1960s and 1970s, ized first by declines in infant and countries, and return migration of the overall pyramid shape had childhood mortality as infectious former emigrants who are above not changed radically by and parasitic diseases are reduced. the median population age all However, the beginnings of fertility The resulting improvement in life of which contribute to population decline can be seen in the roughly expectancy at birth occurs while aging. In the future, international equal sizes of the youngest three fertility tends to remain high, migration could assume a more age groups. The effects of fertility thereby producing large birth prominent role in the aging proand mortality decline can be seen cohorts and an expanding propor- cess, particularly in graying counmuch more clearly in the projected tion of children relative to adults. tries where persistently low fertility pyramid for 2040, which loses its Other things being equal, this ini- has led to stable or even declining strictly triangular shape as the size tial decline in mortality generates a total population size. Shortages of younger 5-year cohorts stabiyounger population age structure. of younger workers may generate lizes and the older portion of the Generally, populations begin to demands for immigrant labor, and total population increases. age when fertility declines and many developed countries have reconsidered their immigration U.S. Census Bureau An Aging World:

32 The picture in developed countries becoming successively smaller. effect of fertility decline usually has has been and will be quite differ- If fertility rates continue as pro- been the driving force in changing ent. In 1960, there was relatively jected through 2040, the aggregate population age structures, current little variation in the size of 5-year pyramid will start to invert, with and future changes in mortality will groups between the ages of 5 and more weight on the top than on the assume greater weight, particularly 34. The effect of the post-world bottom. The size of the oldest-old in relatively aged countries, as dis- War II Baby Boom can be seen in population (especially women) will cussed in the next chapter (Janssen, the 0 14 age range. By 2000, the increase, and people aged 80 and Kunst, and Mackenbach, 2007). Baby Boom cohorts were aged 35 over may eventually outnumber any to 54, and younger cohorts were younger 5-year group. Although the Box 3-1. Demographic Transition Theory and the Age-Sex Composition of Populations Demographers have identified a The theory begins with the triangular in shape, with a wide general progression of changes in observation that, at one time, base that reflects large cohorts of fertility, mortality, and population most developed societies had children at the youngest ages and composition through which high levels of both fertility and progressively smaller cohorts at populations have typically passed mortality and a corresponding low each successive age. in the modern era, articulated as rate of growth (Stage 1). A picture demographic transition theory of such a population has a narrow The next change that affects (Davis, 1945). The concept of pyramidal shape with relatively populations is a decline in the demographic transition admit- few people at the older ages. level of fertility (Stage 3), which tedly is a broad one, and some causes a slowing of the rate of The second stage of demographic argue that it has many permuta- population growth and eventually tions or that there is more than transition consists of a substantial a more even distribution across one form of demographic transidrop in levels of mortality, age groups. A population pyramid tion (see, for example, Coale and especially infant mortality. at the end of this stage is more Watkins, 1986). Still, the theory Because fertility levels stay high, rectangular in shape, and the offers a useful starting point from the result is a rapid increase in older age groups are much which to explain changes in population, particularly at the weightier. observed age-sex compositions younger ages. A pyramid of a during the past century. population at this stage is Population at Stage 1 of the Demographic Transition Age Male Female Percent of total population Population in Stage 2 of the Demographic Transition Age Male Female Percent of total population Population at the End of Stage 3 of the Demographic Transition Age Male Female Percent of total population 20 An Aging World: 2008 U.S. Census Bureau

33 Figure 3-1. Population in Developed and Developing Countries by Age and Sex: 1960, 2000, and 2040 Developed countries Developing countries Developed countries Developing countries 1960 Age Male 80+ Female Millions Sources: United Nations Department of Economic and Social Affairs, 2007b; and U.S. Census Bureau, International Data Base, accessed on December 28, U.S. Census Bureau An Aging World:

34 LEGACY OF FERTILITY DECLInE The most prominent historical factor in population aging has been fertility decline. The generally sustained decrease in total fertility rates (TFRs) in industrialized nations since at least 1900 has resulted in current levels below the population replacement rate of 2.1 live births per woman in most such nations 1 (Figure 3-2). Persistent low fertility since the late 1970s has led to a decline in the size of successive birth cohorts and a corresponding increase in the proportion of the older population relative to the younger population. Fertility change in the developing world has been more recent and more rapid, with most regions having achieved major reductions in fertility rates over the last 35. Although the aggregate TFR remains in excess of 4.5 children per woman in Africa, overall levels in Asia and Latin America decreased by about 50 percent (from 6 to 3 children per woman) during the period 1965 to 1995 and further to around 2.3 today. U.S. Census Bureau projections indicate that fertility in 2008 was at or below the replacement level in more than 40 developing countries. Many of these nations have relatively small populations (e.g., Caribbean and Pacific island nations), but the list includes China, Brazil, and Vietnam three countries that together are home to 24 percent of the world s population. 1 The total fertility rate (TFR) is defined as the average number of children that would be born per woman if all women lived to the end of their childbearing and bore children according to a given set of age-specific fertility rates. The replacement rate is the total fertility rate at which women would have only enough children to replace themselves and their partner. The replacement rate for a given population depends upon the level of mortality, especially infant, childhood, and maternal. Figure 3-2. Total Fertility Rate for Selected Countries by Region: 2008 (Births per woman) Developed countries Austria Belgium Denmark France Germany Greece Italy Norway Sweden United Kingdom Bulgaria Czech Republic Hungary Poland Russia Ukraine Australia Canada New Zealand United States Egypt Kenya Malawi Morocco South Africa Tunisia Uganda Zimbabwe Bangladesh China India Indonesia Israel Japan Malaysia Pakistan Philippines Singapore South Korea Sri Lanka Thailand Turkey Argentina Brazil Chile Colombia Costa Rica Guatemala Jamaica Mexico Peru Uruguay Western Europe Eastern Europe Northern America/Oceania Africa Asia Developing countries Source: U.S. Census Bureau, International Data Base, accessed on January 17, Latin America/Caribbean An Aging World: 2008 U.S. Census Bureau

35 Figure 3-3. Countries/Areas With a Projected Population Decline of at Least 1 Million Between 2008 and 2040 (In millions) Russia 24.1 Japan 23.4 Ukraine 9.5 South Africa 8.4 Germany Italy Poland 4.0 Spain Romania Bulgaria Belarus Czech Republic Taiwan 1.0 Source: U.S. Census Bureau, International Data Base, accessed on January 22, AGInG AnD these decreases will be substantial. rates of 1.4 and 1.2 births per POPuLATIOn DECLInE: Russia s population is expected woman, respectively substantially An unprecedented to shrink by 24 million people below the level needed to replen- DEvELOPMEnT between 2008 and 2040, a drop of ish a population in the absence of 21 percent. Twelve other coutries migration). The developing coun- Some countries are witnessing an are projected to experience a tries that are experiencing or may historically unprecedented demopopulation decline of at least experience population declines graphic phenomenon: simultane- 1 million people during the same typically are also experiencing high ous population aging and overall period (Figure 3-3). In the devel- mortality related to HIV/AIDS. For population decline. European oped world, population decline is example, South Africa s population demographers have sounded coupled with population aging. in 2040 may be 8 million people warning bells for at least the last While Japan s total population is lower than in 2008 due to elevated 35 about the possibility of projected to decrease by nearly mortality. Life expectancy at birth declining population size in indus- 24 million, the population aged 65 in South Africa fell from 60 in trialized nations, but this idea did and over is projected to increase by 1996 to less than 43 in not permeate public discourse 8 million between 2008 and Lesotho, Namibia, and Swaziland until recently. Current population The proportion of the population are also projected to have an HIV/ projections indicate that 28 develaged 65 and older in Japan is pro- AIDS-related decline in their popuoped countries and 7 developing jected to increase from 22 percent lations between 2008 and countries may likely experience in 2008 to 34 percent in This expected population decline declines in the size of their populawill occur at the same time that tions over the upcoming decades; Declines in population size in the proportion aged 65 and over in in some countries (e.g., Estonia, developed countries are the result these countries is increasing. Italy, Japan, and Ukraine), the of extremely low fertility (e.g., decline has already begun. Some of Russia and Japan have total fertility U.S. Census Bureau An Aging World:

36 Figure 3-4. Projected Age-Specific Population Change in Russia Between 2008 and 2040 (Percent) Age Source: U.S. Census Bureau, International Data Base, accessed on January 22, Challenges for planning arise from sufficient numbers of workers for declines in the future or rejuveage-specific population changes. economic expansion. nate national populations unless For example, Figure 3-4 shows that the migration flows are large (i.e., This shifting age structure is seen in Russia, all age groups below in many developed countries, millions annually) and much higher age 60 are likely to decline in size including those that are not likely than in the recent past. So-called between 2008 and 2040, while the to undergo population decline replacement migration does not older age groups increase. This sugin the foreseeable future. Both appear to be a viable solution in gests that the demand for health France and the United Kingdom, for and of itself, but it could buffer the care services might outweigh the example, are projected to experi- likely impact of future aging if it need to build more schools. Since ence an increase in their population occurs in conjunction with other the number of younger adults between 2008 and 2040, but their developments such as increased of working age is anticipated to projected age-specific population labor force participation, especially decline, the working-aged populachange is similar to that for Russia. among women but also at older tion available to contribute to the ages generally, and fertility induceeconomy and pension systems is Various researchers and organiments as explained below (United shrinking while the older nonwork- zations have examined the likely Nations Department of Economic ing population is increasing. At the impact of migration as a counand Social Affairs, 2001; and Fehr, same time, the age-specific changes terbalance to aging. The consenstrongly suggest that companies Jokisch, and Kotlikoff, 2003). sus is that flows of migrants to may have a difficult time attracting Europe will not prevent population 24 An Aging World: 2008 U.S. Census Bureau

37 IS BELOW-REPLACEMEnT mechanisms may produce a con- children and social integration of FERTILITY HERE TO STAY? tinual downward pressure on the younger people (Botev, 2006; and level of fertility. These mechanisms McDonald, 2006). In the 1990s, demographers and include (1) a demographic force, others began to ask if persistent that fewer potential mothers in the OLDER POPuLATIOnS below-replacement fertility was a future will result in fewer births; THEMSELvES OFTEn threat to European and other soci- (2) a sociological factor, that ideal ARE AGInG eties and if so, could it be altered? family size for younger cohorts A theory of the second demois declining; and (3) an economic An increasingly important feature graphic transition evolved, incordimension, that involves conflict of societal aging is the aging of the porating not only the persistence older population itself. A nation s between rising aspirations and of low fertility but also the emerdeclining real income. older population often grows older, gence of widespread cohabitation, on average, as a larger proportion childbearing outside of marriage, Many industrial societies already survives to 80 and beyond. single parenthood, and changes provide incentives for having A nation s oldest-old population in attitudes and norms regard- children, though the explicit aim (defined in this report as people ing marriage and sexual behavior aged 80 and over) consumes is often family welfare rather (Lesthaeghe and Surkyn, 2004; and resources disproportionately to than increasing birth rates. Coleman, 2005). A major question its overall population size (Zhou, Governments employ various is whether the decline in fertility Norton, and Stearns, 2003). The means to affect fertility, includnumerical growth of the oldest old will level off and perhaps reverse, ing direct financial incentives for as population projections typically means, among other things, that additional births; indirect pension assume, or whether birth rates pensions and retirement income (i.e., early retirement) or in-kind will need to cover more people will continue to decline. One study benefits, such as preferential living into their 80s and beyond, (National Research Council, 2000) access for mothers with many health care costs may rise, and examined the experience of the children to subsidized housing; and intergenerational relationships diverse set of countries that have measures to reduce the opportumay take on an added dimenmade the transition to low fertility. nity costs of additional childbearsion if young children know their In few of these countries has fertil- ing (Lutz and Skirbekk, 2005; and great-grandparents. Demographers ity stabilized at rates above two Stamenkova and Chernev, 2006). expect a large numerical growth of children per woman. Such stabiliza- Many European nations have centenarians, whose experiences tion would depend on substantial adopted more generous parenmay yield empirical clues about the proportions of higher-order births tal leave schemes and most have process of aging on both an indi- (i.e., four or more births for some programs to provide cash support vidual and a population level. women), but such higher-order to families with children. In 2004, births are largely anachronistic in Australia introduced a payment of In the mid-1990s, the aggregate industrial-country settings. The A$3,000 for each birth, and South global growth rate of the oldest National Research Council s tenta- Korea offers financial incentives old was somewhat lower than that tive conclusion was that fertility is for couples to have a second child of the world s older population as unlikely to rebound significantly. A (United Nations Economic and a whole, a result of low fertility more recent review of literature on Social Council, 2007). The efficacy that prevailed in some countries the subject found that expert views of such programs is uncertain; around the time of World War I and on the future trajectory of fertility some experts contend that changwere the effects of the influenza pan- roughly divided (Lutz, 2006). ing the demographic landscape demic of People who were Lutz, Skirbekk, and Testa (2006) requires not just birth incentives reaching age 80 in the mid-1990s formulated a low-fertility-trap but broader integrated policies that were part of a relatively small birth hypothesis that self-reinforcing address support for families with cohort. The growth rate of the U.S. Census Bureau An Aging World:

38 Figure 3-5. Global Distribution of People Aged 80 and Over: 2008 (Percent of world total in each country/region) China 17.2 India 7.6 Japan 7.4 Other Asia 11.7 Germany Russia Italy France United Kingdom Spain Other Europe United States 11.7 Brazil Other Latin America/ Caribbean Africa All others All others includes Oceania and Northern America except the United States. Notes: Individual countries with more than 2 percent of the world s total are shown separately. Figures may not sum to 100 percent due to rounding. Source: U.S. Census Bureau, International Data Base, accessed on January 19, world s oldest-old population from 65 and over and 33 percent for the The oldest old constituted 19 per to 1997 was 1.3 percent. Just total population of all ages. 2 cent of the world s older population a few later, however, the in percent in developed 2 low-fertility effects of World War I Past population projections often have countries and 15 percent in develunderestimated the improvement in mortality had dissipated; from 1999 to 2000, rates among the oldest old (National Research oping countries. More than half (52 the growth rate of the world s Council, 2000), and as the next chapter percent) of the world s oldest old points out, the actual number of tomorrow s 80-and-over population jumped to oldest old could be much higher than pres- (and total population) in 2008 lived 3.5 percent, higher than that of the ently anticipated. As the average length of in six countries: China, the United world s older population as a whole life increases, the concept of oldest old will change. Because of the sustained increases States, India, Japan, Germany, and (2.3 percent). Today, the oldest old in longevity in many nations, more detailed Russia (Figure 3-5). An additional information is needed on growing, heteroare the fastest-growing portion of geneous oldest-old populations. In the past, 22 percent lived elsewhere in the total population in many coun- population projections for the world s coun- Europe, 12 percent lived elsewhere tries often grouped everyone aged 80 and tries. On a global level, the 80-andover into a single, open-ended component. In in Asia, and 7 percent lived in Latin over population is projected to the early 2000s, agencies such as the United America and the Caribbean. Nations Population Division and the U.S. increase 233 percent between 2008 Census Bureau s Population Division began Among the 52 study countries, and 2040, compared with 160 producing sets of international population projections that expanded the range of older the percentage of oldest old in the percent for the population aged age groups up to an open-ended category of total population in 2008 was half age 100 and over. 26 An Aging World: 2008 U.S. Census Bureau

39 Figure 3-6. Oldest Old as a Percentage of All Older People: 2008 and 2040 Argentina Bulgaria Japan Morocco Ukraine United States Source: U.S. Census Bureau, International Data Base, accessed on January 22, a percent or less in several devel- constitute 36 percent in 2040 more than 11 million in The oping countries (e.g., Bangladesh, (Figure 3-6). Some European relatively small percentage-point Egypt, Malawi, and Uganda). In nations will experience a sustained increase in Figure 3-6 represents a contrast, the oldest old constituted rise in this ratio, while others will projected absolute increase of over 5.7 percent of the total popula- see an increase during the next 17 million oldest-old people. As tion of Italy and Japan and at least decade and then a subsequent global longevity lengthens and the 5 percent in Belgium, France, decline. A striking increase is likely number of the oldest old multiand Sweden. In general, Western to occur in Japan; by 2040, 38 ply, four-generation families may European nations are above 4 per- percent of all older Japanese are become more common. This poscent, while other developed coun- expected to be at least 80 sibility is offset, however, by trends tries are between 3 percent and 4 old, up from 26 percent in in delayed marriage and rising ages percent. Less than 1 percent of the Most developing countries are at childbearing. In any event, the population is aged 80 and over in a expected to experience modest aging of post-world War II Baby majority of developing nations. long-term increases in this ratio. Boomers could produce a greatgrandparent boom in certain coun- Countries vary considerably in the However, even modest changes tries. Some working adults will need projected age components of their in the proportion of oldest old in to provide educational expenses for older populations. In the United the older population can coincide their children while simultaneously States, the oldest old were about with burgeoning absolute numbers. supporting their parents and pos- 30 percent of all older people in The oldest old in the United States sibly their grandparents. 2008, and they are projected to increased from 374,000 in 1900 to U.S. Census Bureau An Aging World:

40 Figure 3-7. Percent Change in the World s Population: 2005 to 2040 All ages Source: United Nations Department of Economic and Social Affairs, 2007b. RESEARCHERS They also estimate that, over the census recorded about 37,000 EYE InCREASE In course of human history, the odds centenarians, but the actual figure CEnTEnARIAnS of living from birth to age 100 may is thought to be closer to 28,000 have risen from 1 in 20 million to 1 (Krach and Velkoff, 1999). Census While people of extreme old age in 50 for females in low-mortality 2000 recorded more than 50,000 constitute a tiny portion of total nations, such as Japan and Sweden. centenarians, but this figure is artipopulation in most of the world, Scientists are now studying data ficially high due to age misreporttheir numbers are growing, on centenarians for clues about ing, data processing errors, and especially in developed nations. factors that contribute to longev- allocation of extreme age (Humes Thanks to improvements in nutriity (Willcox et al., forthcoming). and Velkoff, 2007). Nevertheless, tion, health, and health care, the For example, a recent analysis it seems clear that the number population aged 100 and over is of U.S. centenarians born in the of centenarians is rising. On the increasing notably. Researchers 1880s suggests that a lean body global level, the United Nations in Europe found that the number mass and having large numbers (Department of Economic and of centenarians in industrialized of children were associated with Social Affairs, 2007b) estimates countries doubled each decade extreme longevity, whereas immibetween 1950 and Using that the population of centenarians gration and marital status were not was about 270,000 as of By reliable statistics from ten Western statistically significant predictors 2040, this number is projected to European countries and Japan, (Gavrilov and Gavrilova, 2007). reach 2.3 million. Figure 3-7 shows Vaupel and Jeune (1995) estimated the projected percent change in that some 8,800 centenarians lived Estimates of centenarians from three age groupings of the older in these countries as of 1990, and censuses and other data sources population and illustrates the that the number of centenarians should be scrutinized carefully, as rapidity of change at the oldest grew at an average annual rate of there are several problems with ages relative to the older populaapproximately 7 percent between obtaining accurate age data on tion as a whole and to the overall the early 1950s and the late 1980s. very old people. The 1990 U.S. population growth rate. 28 An Aging World: 2008 U.S. Census Bureau

41 Table 3-1. Percent Population Aged 65 and Over for 20 Cities Compared With the Respective National Average: Selected Years, 1999 to 2007 (In percent) City, country OLDER PEOPLE MORE LIkELY THAn OTHERS TO LIvE In RuRAL AREAS Urbanization is one of the most significant population trends of the last 50, and according to United Nations estimates, the world will reach a milestone in For the first time in his- tory, half of the global popula- tion is expected to live in urban areas (United Nations Economic and Social Council, 2008). Since urbanization is driven by youthful migration from rural areas to cities, it influences the age distribution in both sending and receiving areas. In general, rural areas have higher concentrations of older residents than do urban areas; this is primarily the result of the migration of Year City National average Beijing, China Budapest, Hungary Calcutta, India Copenhagen, Denmark Dublin, Ireland Havana, Cuba Istanbul, Turkey Johannesburg, South Africa London, United Kingdom Los Angeles, United States Manila, Philippines Montreal, Canada Nairobi, Kenya New York, United States Rio de Janeiro, Brazil San Jose, Costa Rica Shanghai, China Stockholm, Sweden Tokyo, Japan Tunis, Tunisia Source: Compiled by the U.S. Census Bureau from national statistics. young adults to urban areas and, to a lesser extent, of return migration of older adults from urban areas back to rural homes. One study of data for 39 countries from the period showed that the percentage of all older people living in rural areas was higher than the percentage of the total population in rural areas in 27 of the 39 nations, with no difference in 4 nations (Kinsella and Velkoff, 2001). Recent analyses of trends in Northern America indicate that rural populations will continue to be older than urban popula- tions in the United States, while in Canada there is no clear correlation between urban or rural residence and concentrations of older people (Jones, Kandel, and Parker, 2007; and Malenfant et al., 2007). no CLEAR TREnD TOWARD DISPROPORTIOnATE AGInG OF LARGE CITIES Although rural areas tend to be disproportionately older compared with urban areas in general, data for some large cities reveal a relatively high proportion of older residents. In countries where the youthful influx of rural-tourban migrants slowed before 1990, many cities may have aging populations (Chesnais, 1991). Conversely, in countries where urbanization rates remain high and younger residents continue to gravitate toward cities, one would expect the proportion of older people in cities to be lower than for the country as a whole. Data for 20 major cities, however, do not indicate a clear pattern (Table 3-1). The populations of Budapest, Dublin, and Montreal are older than their respective national averages, but this is not the case in Copenhagen, London, Los Angeles, and Tokyo. Istanbul and Nairobi are younger than Turkey and Kenya as a whole, but a similar relationship does not hold in the Chinese cities of Beijing and Shanghai or in Calcutta or Rio de Janeiro. Despite the emergence of two major global demographic trends population aging and urbanization in recent decades, relatively little attention has been paid to the impact of these trends on the health and well-being of older people in cities (for more information, see the 2006 groundbreaking study by Victor Rodwin and Michael Gusmano, 2006). U.S. Census Bureau An Aging World:

42 Box 3-2. Demographic Dividends The prospect of rapid growth of the nonworking older population, with attendant strains on public pension and health care systems, has led to pessi- mism about future economic performance (Peterson 1999). However, rather than being an economic drain, population aging might give rise to a second demographic dividend. Societies rely on formal (public) and/or informal (largely familial) support systems to assist people in older age. Today, many countries are looking to increased savings rates and greater accumulated capital (wealth) as a response to population aging. If countries are successful in encouraging increased savings and wealth, this may constitute a second demographic dividend, i.e., the possibility for enhanced levels of investment and economic growth. Unlike the first demographic dividend, this second dividend is not necessarily transitory in nature. In theory, population aging may An important aspect of changing population age structures is that virtually all countries have experienced, or are projected to experience, a large increase in the share of their population concentrated in the working ages. Other things being equal, this increase in the share of the workingaged population should have a positive effect on per capita income and government tax revenues, leading to what is labeled as the first demographic dividend. This first dividend lasts for decades in many countries; but as populations begin to age, the share of population in the working ages eventually declines, and the dividend becomes negative (Bloom, Canning, and Sevilla, 2003; and Mason, 2006). A major economic challenge for aging societies is to provide for the needs of their older populations while potentially experiencing reduced labor income. 100,000 Figure 3-8. Economic Life Cycle of a Typical Thai Worker Annual per capita labor income and consumption (in baht) Labor income 80,000 60,000 40,000 Consumption 20, Age Source: Chawla, as reported in Lee and Mason, An Aging World: 2008 U.S. Census Bureau

43 Box 3-2. Demographic Dividends Con. produce a permanent increase in capital and in per capita income. Analysis of 228 countries and areas suggests that the duration of the first dividend was relatively short (30 to 35 ) in most industrial and transitional economies, considerably longer in much of Asia and Latin America, and likely to be longer still in Sub- Saharan Africa (Lee and Mason, 2006). Research now seeks to construct economic estimates of both the first and second dividends in order to contrast regional experiences. One interpretation is that the demographic dividends, if fully exploited, would have contributed between 1 and 2 percentage points to income growth during the period for most regions of the world (Lee and Mason, 2006). Demographic dividends are not automatic. Their full exploitation and impact depend on, to a large extent, the existence of strong institutions and policies that translate changes in population age structure into economic growth. For example, weaknesses in the governance and management of pension programs (e.g., significant tax evasion or unsustainable increases in public pension benefits) can offset many potential benefits of demographic dividends, as can persistent high levels of unemploy- ment and underemployment. Thus, social context at least partially determines how the first and second demographic dividends differ throughout the world. In societies with a high prevalence of HIV/AIDS, the disease is eliminating a large portion of the first divi- dend, and there is reason to question whether a sec- ond dividend is possible. More generally, in societies that have experienced an upswing in mortality rates (e.g., many transitional nations in Eastern Europe), excess adult mortality may undercut savings rates and hence undercut the second dividend. Social policy changes also could affect the magnitude of any demographic dividends. The elimination of mandatory retirement ages, for example, might be expected to increase the first dividend and perhaps the second dividend as well. As of now, the second demographic dividend is still a theoretical construct. One analytical tool for estimating dividend levels and related effects is the life-cycle production-consumption function (Figure 3-8). By incorporating the age variable into national income and product accounts, researchers can generate life-cycle composites of consumption and production. They can then use these composites to generate more detailed national transfer accounts, which produce estimates of intergenerational re allocations (including savings patterns, spending on public programs, and family support systems for children and older people) (Mason et al., 2006). The next step will be to construct complementary time series of the age profiles of production, consump- tion, and lifecycle deficit, and to examine how these are influenced by social, economic, and demographic factors. Other researchers (Manton et al., 2007) are looking at the aging of labor forces and changes in disability rates, considering how to increase health and human capital at later ages in order to stimulate increases in gross domestic product (GDP) and enhance a potential second demographic dividend. U.S. Census Bureau An Aging World:

44 ChApTer 4. Life Expectancy and Mortality One of gerontology s liveliest and factors in lowering mortality were has reached at least 80 in most enduring debates centers innovations in industrial and agri- numerous other nations. Levels around the trajectory of human cultural production and distribu- for the United States and most survival. Is average life expectancy tion, which improved nutrition for other developed countries fall in likely to peak around age 85 or large numbers of people. Today s the year range (Figure 4-1). 90, as some have argued, or will research consensus attributes the Throughout the developing world, new ways be found to sustain the gain in human longevity since the there are extreme variations in life large increase in life expectancy early 1800s to a complex interplay expectancy at birth (Figure 4-2). that began in the mid-1800s and of advancements in medicine and While the levels in some developing has continued to unfold dur- sanitation coupled with new modes nations match or exceed those in ing the ensuing 150? While of familial, social, economic, and many European nations, the aversome have ascribed the historical political organization (Riley, 2001). age lifetime in 25 African countries increase primarily to improvements spans fewer than 50. On in medicine and public health, LIFE ExPECTAnCY AT BIRTH average, an individual born in a others have pointed out that the ExCEEDS 80 YEARS In 11 COunTRIES developed country can now expect major impact of improvements to outlive his or her counterpart in both in medicine and sanitation did Life expectancy at birth in Japan not occur until the late nineteenth the developing world by 14. and Singapore has reached 82 century (Thomlinson, 1976; and, the highest level of all Moore, 1993). Earlier important the world s major countries, and U.S. Census Bureau An Aging World:

46 U.S. Census Bureau An Aging World: Life expectancy in Less than to to or more Figure 4-2. Life Expectancy at Birth: 2008 Source: U.S. Census Bureau, International Data Base, accessed on May 27, 2008.

47 TWEnTIETH CEnTuRY LIFE countries began to take different for cardiovascular disease (smok- ExPECTAnCY DOuBLED paths. While female life expectancy ing, hypertension, obesity, etc.); In SOME DEvELOPED continued to rise virtually every- increased alcohol consumption; COunTRIES where, male gains slowed and in changes in dietary composition; some cases leveled off. From the Table 4-1 shows the enormous material deprivation (as reflected early 1950s to the early 1970s, strides that countries have made by wages, poverty, and weakened for example, male life expectancy in extending life expectancy since social safety nets); and increased changed little in Australia, the In some countries (e.g., psychosocial problems (stress, Netherlands, Norway, and the Austria, Greece, and Spain), life negative future expectations, United States. After this period, expectancy more than doubled and suicide). The study looked at male life expectancy again began during the twentieth century. national and international data on to rise. Increases in life expectancy were cause-specific mortality rates, medimore rapid in the first half than In much of Eastern Europe and cal spending, and socioeconomic in the second half of the century. the former Soviet Union, the pace indicators in combination with Expansion of public health services of improvement in the 1950s and data from the Russian Longitudinal and facilities and disease eradicajust early 1960s was extraordinary. Monitoring Survey. Of the six factors tion programs greatly reduced Advances in living conditions and mentioned, two stood out: alco- death rates, particularly among public health policies combined to hol consumption and psychosocial infants and children. From 1900 produce large declines in mortality stress, each explaining about 25 to 1950, people in many Western by reducing some major causes of percent of the deterioration in mor- nations were able to add 20 death (e.g., tuberculosis) to mini- tality. The other four factors found or more to their life expectancies. mal levels (Vishnevsky, Shkolnikov, little support in the data, and the and Vassin, 1991). Resultant gains large unexplained residual under- Reliable estimates of life expec- in life expectancy in excess of 5 scores that clear causal mechanisms tancy for most developing countries per decade were common. By remain poorly understood. prior to 1950 are unavailable. Since the mid-1960s, however, the rate of World War II, changes in life expec- In some countries, particularly in increase had decelerated sharply. tancy in developing regions of the parts of Africa, the HIV/AIDS pan- In the 1970s and 1980s, changes world have been fairly uniform. in female life expectancy at birth demic has had a devastating effect Practically all nations have shown were erratic, while male life expeccontinued improvement, with tancy fell throughout the region on life expectancy (see Box 4-1). The impact on national life expec- some exceptions in Latin America (Bobadilla and Costello, 1997). tancy at birth can be considerable, and more recently in Africa, the given that HIV/AIDS deaths often Following the demise of the Soviet latter due to the impact of HIV/ are concentrated in the childhood Union, the decline in male life AIDS. The most dramatic gains in and mid-adult ages. Estimates expectancy at birth continued in the developing world have been in for the year 2006 suggest that eastern Asia, where aggregate life some countries. The decline has HIV/AIDS has reduced female life expectancy at birth increased from been particularly severe for Russian expectancy at birth by more than less than 45 in 1950 to more men; between 1987 and 1994, male 28 from otherwise prolife expectancy at birth fell 7.3 jected levels in Botswana, Lesotho, than 73 today (United Nations Department of Economic and Social to a level of After rising Namibia, South Africa, Swaziland, Affairs, 2007b). during the mid-1990s, male life and Zimbabwe (Velkoff and Kowal, expectancy again declined in Russia 2007). While the common percep- RISInG LIFE ExPECTAnCY AT (Figure 4-3). Much of this decline tion of HIV/AIDS mortality usually BIRTH IS not universal has been attributed to increases associates HIV/AIDS deaths with in adult male mortality due to a younger adults, the pandemic also While global gains in life expeccombination of factors (Virganskaya has a direct and growing effect on tancy at birth have been the norm, and Dmitriev, 1992; and Murray older populations. In the United unforeseen changes and epidemics and Bobadilla, 1997). One analysis States in 2005, more than twice may reverse the historical pat- (Brainerd and Cutler, 2005) identi- as many people aged 60 and over tern. Beginning in the 1950s, the fied six possible culprits: the break- died of HIV/AIDS as did people typical sustained increase in life down of the medical care system; under age 30 (Centers for Disease expectancy at birth in developed an increase in traditional risk factors Control and Prevention, 2007). 36 An Aging World: 2008 U.S. Census Bureau

49 85 Figure 4-3. Life Expectancy at Birth for Four Countries by Sex: 1950 to 2005 Male Years of life expectancy United States 65 Russia 60 South Korea 55 Zimbabwe Female Years of life expectancy 80 United States 75 Russia South Korea Zimbabwe Sources: United Nations Department of Economic and Social Affairs, 2007b; and U.S. Census Bureau, International Data Base, accessed on January 4, An Aging World: 2008 U.S. Census Bureau

50 Box 4-1. Demographic Impact of HIv/AIDS The HIV/AIDS pandemic is having at birth in 2006 were 22 classic shape of a young populaa direct impact on the age and and 28 lower, respectively, tion wide at the bottom and narsex structure of many countries, than they would have been with- row at the top. By 2030, the effect particularly in Sub-Saharan Africa. out mortality due to HIV/AIDS. of HIV/AIDS on Botswana s popula- To evaluate this impact, national tion structure is likely to be more and international organizations For countries affected severely pronounced. The pyramid has now calculate mortality rates and by HIV/AIDS, the impact is clearly lost the classic young-population life expectancies with and without seen in the age and sex structure shape, and the numbers of people HIV/AIDS-related mortality. Life of the population. Figure 4-4 uses in each age group are much expectancy without HIV/AIDS- population pyramids to illustrate smaller than they would have been related mortality is an estimate the population structure with and in the absence of HIV/AIDS mortalof what life expectancy would be without HIV/AIDS as estimated for ity. These projections indicate that if a given nation had not experi- Botswana in 2006 and projected by 2030, HIV/AIDS will reduce the enced an HIV/AIDS epidemic. In to The population in 2006 size of the 60-and-over population Botswana, for example, the U.S. was smaller than it would have by 45 percent from its expected Census Bureau estimates that been without HIV/AIDS mortality, level without HIV/AIDS mortality. male and female life expectancies but the age structure still had the Figure 4-4. Population With and Without HIV/AIDS-Related Mortality in Botswana by Age and Sex: 2006 and 2030 Estimate without HIV/AIDS-related mortality Estimate with HIV/AIDS-related mortality Estimate without HIV/AIDS-related mortality Estimate with HIV/AIDS-related mortality 2006 Male Age Female Thousands 2030 Male Age Female Thousands Source: Velkoff and Kowal, U.S. Census Bureau An Aging World:

51 Figure 4-5. Highest National Life Expectancy at Birth: 1840 to 2000 (In ) Women Men Note: This figure shows linear-regression trends for annual male and female life expectancies at birth from 1840 through Source: Adapted from Oeppen and Vaupel, HIGHEST RECORDED it is Japan but the linearity of the implies that reductions in mortal- AvERAGE LIFE ExPECTAnCY pattern is remarkable (Figure 4-5). ity are not a sequence of discon- COnTInuES TO RISE Record life expectancy for males nected revolutions but a continualso has shown a linear increase, ous stream of progress. Oeppen A compilation of the highest though the slope of the increase is and Vaupel (2002) note that if the recorded national female life steeper for females. From a his- 160-year trend continued, people expectancies over the period 1840 torical perspective, the apparent in the country with the highest life 2000 showed a steady increase of leveling off of life expectancy in expectancy would live to an aver- 3 months per year (Oeppen and some countries is part of a process age of 100 in approximately Vaupel, 2002). The country with whereby those lagging behind perithe highest average life expecodically catch up and those leading six decades time. tancy has varied over time in fall behind. The long-term view 1840 it was Sweden, and recently 40 An Aging World: 2008 U.S. Census Bureau

52 Figure 4-6. Female Advantage in Life Expectancy at Birth for Selected Countries: 2008 (In ) Developed countries Developing countries Belarus 11.8 France 6.5 Hungary 8.1 Japan 6.9 Russia 13.9 United States 5.8 Spain Chile China Egypt 5.2 Mexico 5.8 Nepal 0.3 Syria 2.8 Source: U.S. Census Bureau, International Data Base, accessed on October 8, FEMALE ADvAnTAGE In exceeds 80 in more than 45 older age. Figure 4-7 illustrates the LIFE ExPECTAnCY AT BIRTH countries and is approaching this usual gender pattern of mortality nearly universal level in many other nations. The at older ages, wherein male rates gender differential usually is smaller The widening of the sex differential are consistently higher than female in developing countries, commonly in life expectancy was a central rates. In Hong Kong and Israel, for in the 3- to 6-year range, and may feature of mortality trends in develbe reversed in some southern Asian instance, male mortality rates for oped countries throughout much of ages 65 to 69 are roughly twice as and Sub-Saharan African societies the twentieth century, although the large as corresponding female rates. where cultural factors (such as low differential has narrowed in some female social status and a stronger Simple explanations of the gen- countries in the last two to three preference for male offspring) and/ der difference in life expectancy decades. In 1900, women in Europe or the differential impact of the still elude scientists because of and Northern America typically outthe apparent complex interplay of HIV/AIDS pandemic contribute to lived men by 2 or 3. Today, higher male than female life expecthe average gap between the sexes biological, social, and behavioral tancy at birth. conditions. Greater use of tobacco is roughly 7 and exceeds 12 and alcohol and higher exposure in parts of the former Soviet FEMALE MORTALITY to occupational hazards have been Union as a result of the unusu- ADvAnTAGE PERSISTS cited as a source of higher male ally high levels of male mortality In OLDER AGE mortality rates (Trovato, 2005; and discussed above (Figure 4-6). This Gee, 2002), suggesting that the gap differential reflects the fact that in Age-specific female mortality rates in life expectancy might decrease most nations, females have lower typically are lower than the correif women increased their use of mortality than males in every age sponding male rates in childhood tobacco and alcohol and their group and for most causes of and the working ages, and this participation in the labor force. death. Female life expectancy now female advantage continues into Data from industrialized countries U.S. Census Bureau An Aging World:

53 Figure 4-7. Mortality Rates at Older Ages for Three Countries by Sex: 2004 (Deaths per 1,000 population) Costa Rica Male Female Hong Kong, S.A.R Israel Source: United Nations Department of Economic and Social Affairs, Demographic Yearbook tend to show a narrowing of the that many developing countries expectancy should increase if gender gap in the last two decades, are experiencing increases in this goal is approached (United although the gap has widened in alcohol and tobacco consumption Nations, 2008). Another factor parts of Eastern Europe and the and vehicular as well as industrial that may promote a widening former Soviet Union. accidents, all of which tend, at gender gap is education, which is least initially, to adversely affect positively related to survival. As We might expect to see a widening men more than women. The United women catch up to men in terms of the gender gap in life expec- Nations has set a major decrease of educational attainment, female tancy in developing countries in in maternal mortality levels as one survival and health status may upcoming decades, along the lines of its Millennium Development improve (Knodel, Ofstedal, and of the historical trend in industrial- Goals, and the gender gap in life Hermalin, 2002). ized nations. Evidence suggests 42 An Aging World: 2008 U.S. Census Bureau

54 Figure 4-8. Evolution of Life Expectancy at Age 65 in Japan, the United States, and France by Sex: 1950 to 2004 (In ) Japan United States 1 France Male Female Latest U.S. data refer to Source: University of California, Berkeley; and Max Planck Institute for Demographic Research, Human Mortality Database, accessed on November 7, OLD-AGE MORTALITY RATES DECLInInG OvER TIME In countries where infant and childhood mortality rates are still relatively high, most of the improvement in life expectancy at birth results from helping infants survive the high-risk initial of life. But when a nation s infant and childhood mortality reach low levels, longevity gains in older segments of the population account for a greater share of the overall improvement in life expectancy (Gjonca, Brockmann, and Maier, 2000; and Mesle and Vallin, 2006). Many countries are experiencing a rise in life expectancy at age 65, as exemplified by the data for three countries in Figure 4-8. The average Japanese woman reaching age 65 in 2004 could expect to live an additional 23.3 and the average man more than 18. Life expectancy for Japanese women at age 65 increased 52 percent between 1970 and 2004, compared with an increase in life expectancy at birth of 15 percent. A longer-term investigation of change in Britain discovered that while life expectancy at age 65 increased 1 year between 1840 and 1960, it has increased by 1 year in each of the decades since 1960 (Stewart and Vaitlingam, 2004). Figure 4-9 shows across-the-board declines in mortality in two older age groups during a fairly recent 10-year period. In general, mortality improvements for people aged 70 to 74 have been larger than for people aged 80 to 84. U.S. Census Bureau An Aging World:

55 Figure 4-9. Percent Change in Death Rates for Two Older Age Groups in Selected Countries by Sex: 1994 to to to 84 Female Australia 1 Finland Germany Hungary Japan Mauritius 1 Ukraine United States 10 7 Male Australia Finland Germany Hungary Japan Mauritius 1 Ukraine United States Data for Australia and Mauritius are for 1993 and Source: United Nations Department of Economic and Social Affairs, Demographic Yearbook 1996 and The pace at which death rates at the life expectancy of 80-year- remained at 1950 levels. In absoadvanced ages decline will affect old women was about 50 percent lute terms, more than one-half future numbers of the older and higher in the mid-1990s than in million oldest-old British women especially of the very old popula Consequently, the number were alive in the mid-1990s than tion. One study in England and of female octogenarians was about would have been without mortal- Wales (Vaupel, 1998) found that 50 percent higher than it would ity improvement. have been had oldest-old mortality 44 An Aging World: 2008 U.S. Census Bureau

56 Figure Major Causes of Death in the European Union by Age: 2001 Percent Other External causes of injury and poisoning Cancer 1 Diseases of the digestive system Diseases of the respiratory system Diseases of the circulatory system Total Age group 1 Cancer refers to malignant neoplasms including leukemias and lymphomas. 2 In the age group 0 (less than 1 year), the principal causes of death were certain conditions originating in the perinatal period (48 percent) and congenital malformations and chromosomal abnormalities (28 percent), which are included in Other. Note: Data refer to 25 European Union countries. Source: Adapted from European Commission, 2007, based on Eurostat mortality statistics. CARDIOvASCuLAR DISEASE cerebrovascular (stroke), and aggregate 25-country European THE PREEMInEnT CAuSE hypertensive diseases increase Union in While CVDs may be OF DEATH AMOnG with age. One comprehensive anal- considered diseases of affluence, OLDER PEOPLE ysis of developed nations (Murray their prominence is not limited to and Lopez, 1996) attributed nearly developed countries. CVDs have Summary mortality indexes, such 60 percent of all deaths to women become the leading cause of death as life expectancy, are useful for aged 60 and over in the early in all developing regions of the broad comparative purposes but 1990s to CVDs; the corresponding world, except for Sub-Saharan may mask changes in mortality by figure for older men was 50 per- Africa (Mathers et al., 2005). In age and/or cause of death. Analysis cent. In recent, death rates developing countries as a whole, of cause-specific changes in mordue to CVDs have declined at older CVDs cause twice as many deaths tality can help professionals devise ages in many developed countries. as HIV/AIDS, tuberculosis, and medical or nutritional interventions Nevertheless, CVDs remain the malaria combined (Lopez et al., to affect overall longevity and the primary killer among older popu- 2006; and Gaziano, 2007). quality of lived at older ages. lations (European Commission, Chapter 5 discusses in more detail Death rates due to cardiovas- 2007). Figure 4-10 shows the the growing impact of CVDs in cular diseases (CVDs) a broad proportions of all deaths attributed developing countries. category that includes heart, to major disease categories for the U.S. Census Bureau An Aging World:

57 Figure Lifetime Risk of Lung Cancer in 13 European Countries by Sex: Circa 2006 (In percent) Male Female Hungary Poland Russia Belgium Italy Romania France Denmark Netherlands Germany United Kingdom Finland Sweden Note: Data refer to cumulative lifetime risk during the ages 0 to 74. Source: Adapted from Ferlay et al., PERSISTEnT COnCERn all cancer deaths to males in devel- had become the third leading ABOuT LunG CAnCER oped countries and 12 percent cause of death overall in developed of all cancer deaths to females. countries (Lopez et al., 2006). In Although deaths from CVDs Proportions for the 60-and-over the United States, male death rates are expected to remain most population were virtually identi- from lung cancer (including canprominent in the future (see cal. More recent data show that cer of the trachea and bronchus) Sonnenschein and Brody [2005] for male death rates from lung cancer peaked around 1990, while female projections of proportionate morappear to have peaked and are death rates rose during the period tality in the United States), a major now falling in some countries and (National Center for concern of health practitioners in stabilizing in many others, per- Health Statistics, 2006). Lung canthe industrialized world is the rise haps portending future declines. cer remains the preeminent cause in lung cancer among older women Conversely, female death rates of cancer death in Europe (Ferlay et as a result of increased tobacco use from lung cancer have been rising al., 2007). In some countries, the since World War II. Estimates for rapidly since 1950, in proportion estimated lifetime risk for men havthe early 1990s (Murray and Lopez, to the large increases in cigarette ing lung cancer exceeds 10 percent 1996) suggested that lung cancer consumption that began several (Figure 4-11). was responsible for 30 percent of decades ago. By 2001, lung cancer 46 An Aging World: 2008 U.S. Census Bureau

58 Box 4-2. Suicide Rates Much Higher Among Older Men Than Women Suicide rates in 30 countries with relatively reliable are happier than nonmarried elders (see Chapter 6); data (Table 4-2) are consistently higher among men and (2) older women have higher rates of disability than women in all age groups, including ages 65 and than do older men (see Chapter 5). These factors over. This gender difference is seen in societies as suggest that older women would have higher rates disparate as Singapore, Cuba, Israel, and Bulgaria. of suicide than older men, but this is not the case. Suicide rates are most likely to increase with age among men and are highest at ages 75 and over Among the 30 countries examined, South Korea and in two-thirds of the countries shown in Table 4-2. Hungary had the highest suicide rates for both older Suicide rates for women also tend to rise with age, men and women. The reported rate for South Korean although peak rates for women occur before age 75 men aged 75 and over is nearly four times higher in about half of the countries shown. The gender than the rate in Japan and 20 times higher than that difference may be surprising in view of two considand in Ireland. Cuba, Hong Kong, Kazakhstan, Russia, erations: (1) the average woman outlives her spouse, Ukraine have comparatively high rates among and many studies have shown that married elders their 65-and-over male populations, while Hong Table 4-2. Suicide Rates for Selected Age Groups in 30 Countries: Circa 2004 (Deaths per 100,000 population) Male Female Country Year 15 to to to and over 15 to to to and over Europe Bulgaria Denmark Finland France Germany Hungary Ireland Italy Netherlands Norway Poland Portugal Russia Switzerland Ukraine United Kingdom Other Countries/Areas Australia Canada Chile Cuba Hong Kong Israel Japan Kazakhstan New Zealand Panama Singapore South Korea Thailand United States Source: World Health Organization, <www.who.int/mental_health/prevention/suicide/country_reports/en/>, accessed on August 8, U.S. Census Bureau An Aging World:

59 Box 4-2. Suicide Rates Much Higher Among Older Men Than Women Con. the very gradual rise seen in France until the mid- 1980s or the downward tendency observed in the United Kingdom. More often, national rates have fluctuated with no perceptible pattern. The unpre- dictability of suicide trends is perhaps best illustrated by the case of the Netherlands. Dutch society is widely recognized as being more tolerant of vol- untary euthanasia than are other Western societies, and one might think it would also have higher rates of recorded suicide. However, the country s rates are lower than the industrialized-country average for most age groups, including older people, and have varied little during the past 30. Kong, Japan, Singapore, and Switzerland have comparatively high rates among older women. Levels for older men in the United States are average when compared with other countries, whereas the U.S. rate for women aged 65 and over is relatively low. Although some of these international differentials may be artificial due to variation in the reporting and/or diagnosis of suicide, their sheer magnitude suggests that real international differences do exist. Data from the World Health Organization for the past 35 to 40 do not show any clear trend in suicide rates for the older population in the world s more developed countries. Few nations have experienced 48 An Aging World: 2008 U.S. Census Bureau

60 ChApTer 5. Health and Disability Many societies worldwide have mortality declines result primarily toward a greater incidence of experienced a change from con- from the control of infectious and chronic and degenerative diseases. 1 ditions of high fertility and high parasitic diseases at very young mortality to low fertility and low ages. As children survive and grow, EPIDEMIOLOGICAL mortality, a process widely known they are increasingly exposed to TRAnSITIOn SHIFTS as demographic transition. Related risk factors associated with chronic THE SuRvIvAL CuRvE to this trend is epidemiologic diseases and accidents. When fertil- Figure 5-1, which shows survival transition, a phrase first used in the ity declines and populations begin curves for U.S. White females early 1970s (Omran, 1971) to refer to age, the preeminent causes of in 1901 and 2003, illustrates a to a long-term change in leading death shift from those associated general pattern seen in developed causes of death, from infectious and with infant and childhood mortality 1 As with the concept of demographic acute to chronic and degenerative. to those associated with older age. transition, there are permutations and coun- In the typical demographic transi- Eventually, the increase in the num- terexamples of epidemiological transition, now sometimes referred to as health transition described in Box 3-1, initial ber and proportion of older adults tion (Salomon and Murray, 2002; Vallin and shifts national morbidity profiles Mesle, 2004; and Riley, 2005). Figure 5-1. Survival Curve for U.S. White Females: 1901 and Percent surviving Age Sources: U.S. Census Bureau, 1936; and Arias, U.S. Census Bureau An Aging World:

61 Figure 5-2. Proportion of All Deaths Occurring at Age 65 or Over in 29 Countries/Areas: Circa 2001 (In percent) Haiti French Guiana Nicaragua Venezuela Colombia Dominican Republic Belize Ecuador El Salvador Brazil Peru Paraguay Mexico Panama Trinidad & Tobago Virgin Islands (US) Costa Rica St. Lucia Chile Dominica Puerto Rico Argentina Guadeloupe Cuba Barbados Bermuda Uruguay United States Canada Source: Pan American Health Organization, countries. The curve for 1901 approximately 50, and the age at death was above 83. represents the early stages of the median age at death (the age at The proportion surviving is now epidemiological transition when which 50 percent of females sub- quite high at all ages up to age the level of infant mortality is high; ject to the mortality risks of , and the survival curve at older mortality is considerable through could expect to survive) was about ages is approaching a more rectanthe middle ; and mortal- 60. By 2003, the survival gular shape as a result of relatively ity increases at the later ages. curve had shifted substantially. higher chronic-disease mortality at Female life expectancy at birth was Average female life expectancy had older ages. risen to 80, and the median 50 An Aging World: 2008 U.S. Census Bureau

62 Table 5-1. Rank Order of the Ten Leading Causes of Death in Taiwan: 1956, 1976, 1996, and 2005 Rank GDEC Cerebrovascular disease Malignant neoplasms Malignant neoplasms 2 Pneumonia Malignant neoplasms Cerebrovascular disease Cerebrovascular disease 3 Tuberculosis Accidents Accidents Heart disease 4 Perinatal conditions Heart disease Heart disease Diabetes mellitus 5 Vascular lesions of CNS 2 Pneumonia Diabetes mellitus Accidents 6 Heart disease Tuberculosis Cirrhosis/chronic liver disease Pneumonia 7 Malignant neoplasms Cirrhosis/chronic liver disease Nephritis/nephrosis Cirrhosis/chronic liver disease 8 Nephritis/nephrosis Bronchitis 3 Pneumonia Nephritis/nephrosis 9 Bronchitis Hypertensive disease Hypertensive disease Suicide 10 Stomach/duodenum ulcer Nephritis/nephrosis ulcer Bronchitis 3 Hypertensive disease 1 GDEC includes gastritis, duodenitis, enteritis, and colitis (except diarrhea of newborns). 2 CNS refers to the central nervous system. 3 The bronchitis category for 1976 and 1996 includes emphysema and asthma. Source: Taiwan Department of Health. DEvELOPInG-COunTRY infectious and parasitic diseases Research into patterns of change TRAnSITIOn MOST that dominated Taiwanese mortal- in mortality, sickness, and dis- APPAREnT In ity in the mid-1950s have given ability has suggested that these LATIn AMERICA way to chronic and degenerative three factors do not necessarily diseases. By 1976, cerebrovascular evolve in a similar fashion. A four- Developing countries are in various disease and cancers had become country study (Riley, 1990) noted stages of epidemiological transithe leading causes of death. The that in Japan, the United States, tion. Aggregate regional change has situation in 2005 was similar to and Britain, mortality decreased been most evident in Latin America that in 1976, except that the rela- and sickness (morbidity) increased, and the Caribbean, where the lattive importance of diabetes rose while in Hungary, mortality est data show that cardiovascular substantially, tuberculosis was no increased and sickness decreased. diseases (CVDs) were the leading 2 longer a major killer, and suicide Discrepancies between the trends in cause of death in 26 of 32 countries became a prominent concern. mortality, morbidity, and disability and areas (Pan American Health Although time series data for have generated competing theories Organization, 2007). Most deaths much of the remainder of Asia and of health change, several of which from chronic and degenerative ailfor Africa are lacking, scattered may be characterized as the followments occur at relatively old ages. evidence suggests the increasing ing: a pandemic of chronic disease Comparative data circa 2001 for the importance of chronic disease pat- and disability (Gruenberg, 1977; Western Hemisphere (Figure 5-2) terns in adult populations. and Kramer, 1980); the compression show that half or more of all deaths of morbidity into a short period in a majority of nations occur at IS A LOnGER LIFE before death (Fries, 1990); dynamic ages 65 and over. A BETTER LIFE? equilibrium (Manton, 1982); and the The pace of epidemiological Chapter 4 pointed out that con- postponement of all morbid events change in some eastern and southtinual increases in life expectancy, to very old ages (Strehler, 1975). eastern Asian nations has been especially at older ages, have been The World Health Organization especially rapid. In the case of the norm in most countries world- has proposed a general model of Singapore, where life expectancy at wide. As people live longer, the health transition that distinguishes birth rose 30 in little over a quality of that longer life becomes between total survival, disabilitygeneration (from 40 in 1948 a central issue for both personal free survival, and survival without to 70 in the late 1970s), the and social well-being. Are individu- 2 The author s broader review of hisshare of cardiovascular deaths rose als living healthier as well as longer torical data concludes that the relationship from 5 percent to 32 percent of all between falling sick and dying from sicklives, or are ill health and disabilideaths, while deaths due to infecness has shifted over time, and that the link ties characteristic of older? between health risks and death has been tious diseases declined from 40 unstable across time. The risk of being sick In aging societies, the answer to has increased as a result of various factors percent to 12 percent. Data from this question will affect national among them earlier and better detection of Taiwan (Table 5-1) exemplify the sickness, declining mortality, and rising real health systems, retirement, and the income. The implication is that protracted sickdemand for long-term typical shift in causes of death; the care. ness is a by-product of these achievements. U.S. Census Bureau An Aging World:

63 disabling chronic disease. In other latter models, however, require the opposite pattern (Population words, it is desirable to disaggre- longitudinal data that currently are Council, 2003). Researchers began gate life expectancy into different unavailable or still being developed to disaggregate disability into health states to better understand in most nations. more severe and less severe the relative health of populations. categories, and the consensus in As of 2008, it remains impossible Thus, a general survival curve, such developed countries was that the to strictly compare estimates of as that in Figure 5-1, can be parti- overall decline in disability was health expectancy among nations tioned into different categories that primarily the result of declines in due to different computational include overall survival, survival the more-severe forms (Robine and methods and differences in conwithout disability, and survival Romieu, 1998), as measured by limcepts and definitions that define without disease. itations in ADLs. Changes in light or the basic data. Important distincmoderate disability, often meations between impairments, dis- CROSSnATIOnAL abilities, and handicaps can lead sured with regard to IADLs rather ASSESSMEnT OF to different measures of health than ADLs, were mixed (Jacobzone, HEALTH ExPECTAnCY status. Because the term disability Cambois, and Robine, 1999). REMAInS ELuSIvE is defined in many ways, national A more recent analysis (Lafortune Since the early 1970s, research has estimates of disability may vary et al., 2007) focused specifically been moving toward the develop- enormously. The most commonly on trends in severe disability, ment of health indexes that take used measurement tools are scales defined as having one or more into account not only mortality that assess the ability of individu- limitations in basic ADLs. This but also various gradations of ill als to perform activities of daily liv- study examined trend data up to health (e.g., Robine et al., 2003). ing (ADLs) such as eating, toileting, 2005 for people aged 65 and over Health expectancy has become a and ambulation, as well as instruin 12 Organisation for Economic generic term for a class of popula- mental activities of daily living Co-Operation and Development tion indicators that estimate the (IADLs) such as shopping and using (OECD) countries. The conclusion average time that someone could transportation. These measures was less optimistic than the earlier expect to live in various states originated in industrialized socipicture a distinct decline in severe of health (Mathers, 2002). Health eties where debate has centered disability among older people was expectancy can be measured in on long-term care systems and seen in only 5 of the 12 counvarious ways; for example, individuals ability to function in tries (Denmark, Finland, Italy, the in good health, free from dis- everyday life. 3 Netherlands, and the United States) ability, or free from specific Some efforts have attempted to (see Box 5-1 for more information diseases. Healthy life expectancy distill data from various national on the United States). Data from is perhaps the most commonly studies into reasonably comparable Australia and Canada indicated a used term, and most estimates of composites. A review of trend data stable rate, while Belgium, Japan, healthy life expectancy are derived from the latter part of the twen- and Sweden reported an increasfrom calculations of disability-free tieth century in nine developed ing rate of severe disability at ages life expectancy using a methodolcountries plus Taiwan suggested 65 and over. Data from different ogy pioneered by Sullivan (1971). that disability generally was declin- national surveys within France and This methodology employs crossing at older ages (Waidmann and the United Kingdom gave inconsectional prevalence data but may Manton, 1998), though more recent sistent results and did not allow a produce results that underestimate information from Taiwan suggests determination of trend. 4 temporal trends in a given population. Recognizing that these earlier 3 ADL measures vary along several dimensions, computational approaches could including the number of activities 4 Several factors other than actual considered and the degree of independence increases in chronic disease incidence may not capture the full dynamic nature in performing physical activities. ADLs do contribute to reported declines in healthy of disability, multistate models not cover all aspects of disability, however, life expectancy, including increased survival and are not sufficient by themselves to of chronically ill individuals due to improvehave been developed to incorporate estimate the need for long-term care. Some ments in medical care, earlier diagnosis of older people have cognitive impairments not chronic diseases, greater social awareness of processes, such as recovery and measured by ADL limitations, which may or disease and disability, earlier adjustment to rehabilitation, into the calculations may not be captured by IADL measures. Many chronic conditions due to improved pension questions also arise regarding the validity and and health care/delivery systems, and rising (Khoman and Weale, 2007). These applicability of such measures in different expectations of what constitutes good health cultural settings. or normal functioning. 52 An Aging World: 2008 U.S. Census Bureau

64 Box 5-1. Disability Decline in the united States Mounting evidence suggests that disability rates in Survey found declines in the percentage of older later life have been declining in the United States. people reporting disability (Freedman et al., 2007). Data from six rounds of the U.S. National Long Term Changes in the prevalence of heart and circulatory Care Survey demonstrate that the disability rate conditions and visual limitations played a major role among people aged 65 and over declined over a in this decline, although it appeared that increases in 23-year period (Manton, Gu, and Lamb, 2006) (Figure obesity have had a countervailing effect. Other posi- 5-3). At least five other U.S. surveys, while varying in tive factors include increased use of assistive technolcontent and nature (both cross-sectional and longitu- ogies and changes in socioeconomic characteristics, dinal), have yielded findings that support a temporal such as higher educational attainment and declines in decline. Most recently, an examination of data from poverty (Schoeni, Freedman, and Martin, 2008) from the U.S. National Health Interview Figure 5-3. Chronic Disability Decline in the United States: 1982 to 2005 (Percent of older people in each category) ADL ADL 2 IADL only 3 Institution Nondisabled / ADL refers to difficulty with three or more basic activities of daily living (ADLs), such as eating, toileting, dressing, bathing, and ambulation ADL refers to difficulties with one or two of these items. 3 IADL only refers to difficulty with one or more instrumental activities of daily living (IADLs), such as preparing meals, managing money, shopping, performing housework, and using a telephone. 4 Institution refers primarily to nursing homes. Note: Data refer to the Medicare-enrolled population aged 65 and over. Source: Manton, Gu, and Lamb, U.S. Census Bureau An Aging World:

65 Table 5-2. Average Annual Growth Rate in the Prevalence of Selected Conditions Among People Aged 65 and Over: Selected Periods, 1980 to 2005 Country Period covered Arthritis Heart problem Diabetes Hypertension Obesity Australia (NA) Belgium Canada Denmark (NA) (NA) 3.3 (NA) 1.6 Finland (NA) Italy Japan (NA) Netherlands Sweden (NA) (NA) United Kingdom (NA) 7.4 (NA) 3.2 United States (NA) Not available. Represents or rounds to zero. 1 The trend for obesity in Canada refers to ages 75 and over. Source: Lafortune et al., PREvALEnCE OF related to those conditions. Parker older adults in Latin America and CHROnIC COnDITIOnS and Thorslund (2007) also con- the Caribbean reveal that 3 out of IS InCREASInG WHILE clude that trends in disease and every 4 women reported suffer- DISABILITY IS DECREASInG functional limitation have taken ing from at least 1 of 3 disabling In DEvELOPED COunTRIES different directions, implying an conditions: arthritis, incontinence, increased need for rehabilitative and poor vision, with the latter Considering overall (light, modand assistive technologies. contributing to falls, hip fractures, erate, and severe) disability, it and depression (Pan American appears that an increase in chronic FEMALE ADvAnTAGE Health Organization, 2007). More health conditions is accompanied In LIFE ExPECTAnCY women than men who reach older by a decrease in reported disabil- PARTIALLY OFFSET BY age can expect to spend a greater ity. The prevalence of five chronic DISABILITY proportion of their remaining diseases and risk factors was, The previous chapter documented in a severely disabled state. with a couple of exceptions, seen the near-universal gender gap in Several possible explanations of to increase recently in each of the life expectancy in favor of women. this difference have been procountries in Table 5-2 (Lafortune et Data on health expectancies around posed, including differential use of al., 2007). This finding agrees with the world indicate that a larger per- institutional care, higher rates of a separate analysis of U.S. survey centage of women than men report disabling diseases (e.g., depression data (Freedman et al., 2007) that being disabled. Women acquire and arthritis), reporting biases, and notes a pattern of rising prevalence more co-morbid conditions as a physiological differences (Cambois, of chronic conditions accomparesult of living longer (Robine and Desquelles, and Ravaud, 2003; and nied by declines in the share of Jagger, 2005). Data from the Survey Newman and Brach, 2001). respondents who report disability on Health, Well-Being and Aging of 54 An Aging World: 2008 U.S. Census Bureau

66 Box 5-2. Socioeconomic Correlates of Mortality and Disability Diverse studies have identified a number of socio- including people in old age, relative to other marital economic factors that affect health and longevity. statuses, and the effects may be larger for older men Education is perhaps the most widely studied vari- than for older women (Schone and Weinick, 1998). able. Thirty-five ago, Kitigawa and Hauser The socioeconomic factors mentioned above are, to (1973) observed that people with higher education some extent, interrelated, and current analyses are tend to live longer. In 2008, researchers demonstrated interested in assessing the interactions of more than that life expectancy for better-educated people in one variable with an individual s health. A recent the United States rose by about 3 during the Danish study, for example, found that the social period , compared with half a year for gap in mortality levels widened during the past 25 less-educated people (Meara, Richards, and Cutler,, especially for women with low education 2008). Noticeable differences in cause-specific mortallevels (Bronnum-Hansen and Baadsgaard, 2007). As ity among middle-aged and older women and men more studies throughout the world collect longituby educational level have been observed in eight dinal data, researchers increasingly will be able to European populations (Huisman et al., 2005). Studies understand multivariable effects over time. Survey in the United States and Canada have found that level data from the Health and Retirement Study (HRS) in of education is one of the few determinants consisthe United States show not only a strong correlation tently associated with maintaining good health in midbetween health and wealth but an added marriage dle age and beyond (Martel et al., 2005; and Lafortune correlation as well (U.S. National Institute on Aging, et al., 2007), and increased levels of education have 2007). Data from the initial (1992) survey wave been identified as a potential factor influencing disindicated that average household wealth for houseability decline (Freedman and Martin, 1999). holds where both partners were in excellent health Income is another correlate of health. Low-income was more than ten times higher than for households people aged 55 to 84 in the United States are more where both partners were in poor health (Willis, likely than wealthier older adults to feel limited in 1999). Such findings might have implications for basic physical activities, such as climbing stairs assessing the future health status of older populaand lifting objects (Minkler, Fuller-Thomson, and tions. For example, if marriage equates with better Guralnik, 2006). Cohort studies of British civil ser- health among older individuals, do rising rates of vants have demonstrated the importance of social divorce and increased proportions of never-married class and occupational grade people from lower individuals portend poorer average health? And what grades age faster in terms of a quicker deteriora- of other life dimensions? A considerable amount of tion in physical health compared with workers from current research is focused on not only the social but higher grades (Chandola et al., 2007). Being mar- also the psychological and biological influences on ried encourages healthier behaviors in many adults, health (e.g., Weinstein, Vaupel, and Wachter, 2007). U.S. Census Bureau An Aging World:

67 Figure 5-4. Age and Sex Structure of Disability in the Philippines: 2005 Male Age Female Under Percent Note: Each bar represents the number of disabled people in that age/sex group expressed as a percent of all disabled people. Source: Census data provided by the Philippines National Statistics Office. DISABILITY PREvALEnCE census. 5 The highest proportions age of 21. Even if disability IS LIkELY TO InCREASE In of people with disabilities generally rates were to decline somewhat DEvELOPInG COunTRIES were seen in the older age groups. over time, the aging of the Filipino The median age of people with population implies increasing num- The number of disabled people in disability was 49, compared bers of disabled people. In view most developing countries seems with an overall median population of declining fertility and changing certain to increase as a correlate 5 Censuses are not the best data col- family structures (see Chapter 7), of population growth. Figure 5-4 lection instruments to measure disability families in developing countries illustrates the age structure of since census questions tend to elicit yes/ no responses, and the census process does likely will be challenged to provide disability in the Philippines as not allow in-depth probing of respondents the future service and care requiremeasured in the 2000 population health statuses. Still, census data can provide ments of older people. a broad picture of disability by age and sex at the population level. 56 An Aging World: 2008 U.S. Census Bureau

68 Table 5-3. Rank Order of Disease Burden in High-Income Versus Lowand Middle-Income Countries: 2001 (Disease burden measured in disability-adjusted life ) Rank BuRDEn OF noncommunicable DISEASE IS GROWInG High-income countries epidemiological change is the Global Burden of Disease (GBD) Project, currently spearheaded by the World Health Organization, the World Bank, and the U.S. National Institutes of Health. Using a com- putational concept known as disability-adjusted life, this project attempts to measure global, regional, and country-specific disease burdens in a baseline year, and to project such burdens into the future. Table 5-3 contrasts the estimated rank order of disease burden for the ten leading disease categories in high-income countries and in low- and middle- income countries as of In high-income countries, most of the disease burden flows from chronic conditions, such as CVDs and neu- ropsychiatric disorders. In low- and middle-income nations, the most important factors in disability burden at the turn of the twenty-first century were problems related to Two decades ago, the World Health Organization noted a distinction in prominent causes of disability between developed and developing countries. In the latter, disability stemmed primarily from malnu- trition, communicable diseases, accidents, and congenital condi- tions. In industrialized countries, disability resulted largely from the chronic diseases discussed ear- lier CVD, arthritis, mental illness, and metabolic disorders as well as accidents and the consequences of drug and alcohol abuse. As economies in developing countries expand and the demographic and epidemiological pictures change, the nature and prevalence of vari- ous disabilities may also change. A major ongoing effort to understand and predict the effect of Disease or injury Low- and middle-income countries 1 Ischemic heart disease Perinatal conditions 2 Cerebrovascular disease Lower respiratory infections 3 Unipolar depressive disorders Ischemic heart disease 4 Alzheimer and other dementias HIV/AIDS 5 Lung, trachea, and bronchus cancers Cerebrovascular disease 6 Hearing loss Diarrhoeal diseases 7 Chronic obstructive pulmonary disease Unipolar depressive disorders 8 Diabetes mellitus Malaria 9 Alcohol use disorders Tuberculosis 10 Osteoarthritis Chronic obstructive pulmonary disease Source: Lopez et al., maternity and infant survival and to respiratory infections (Lopez et al., 2006). During the next two to three decades, experts expect a major shift in disease burden such that noncommunicable diseases will no longer be seen primarily as diseases of affluent societies (Adeyi, Smith, and Robles, 2007). The GBD project estimated that in 2002, noncommunicable diseases accounted for 85 percent of the burden of disease in high-income countries, compared with 44 percent in low- and middle-income countries. Noncommunicable diseases already account for as much of the burden of disease in low- and middle-income countries as all communicable diseases, maternal and perinatal conditions, and nutritional deficiencies combined (Figure 5-5). By 2030, according to projections, the share of the burden attributed to noncommunicable diseases in low- and middle-income countries will exceed one-half, while the share attributed to communicable diseases will fall to one-third. Noncommunicable diseases already account for more than 87 percent of the burden for the 60-and-over population in low-, middle-, and high-income countries. The critical issue for low- and middle-income countries is how to mobilize and allocate resources to address chronic diseases as well as the relatively high prevalence of communicable diseases. U.S. Census Bureau An Aging World:

69 Figure 5-5. The Increasing Burden of Chronic Noncommunicable Diseases on Countries by Income Level: 2002 and 2030 Low- and middle-income countries Injuries 12% Injuries 14% Communicable, maternal, perinatal, and nutritional conditions 44% Communicable, maternal, perinatal, and nutritional conditions 32% Noncommunicable diseases 44% Noncommunicable diseases % 2030 High-income countries Injuries 9% Injuries 7% Communicable, maternal, perinatal, and nutritional conditions 6% Communicable, maternal, perinatal, and nutritional conditions 3% Noncommunicable diseases 85% Noncommunicable 2002 diseases 89% 2030 Source: Lopez et al., OBESITY MAY adults worldwide are obese and 2007). It seems clear that, over THREATEn IMPROvEMEnTS a majority are estimated to live in such a relatively short period of In LIFE ExPECTAnCY developed countries (World Health time, genetic factors are not the Organization, 2000). The average cause of rising obesity. Rather, The rise in the number of people level of obesity in OECD countries increased average weight is a funcwho are overweight or obese has has risen by 8 percent during the tion of how much people eat, the been described as a global panlast two decades (Bleich et al., types of foods consumed (e.g., demic. 6 An estimated 300 million more energy-dense, nutrient-defi- 6 Obesity is defined as weight that is dan- BMI categories are obese (BMI of 30 or higher), gerously excess because of its high proportion overweight (25 to 29.9), normal (18.5 to 24.9), cient foods), and lifestyle changes of body fat relative to lean body mass (OECD, and underweight (less than 18.5). It should related to physical and sedentary 2006b). The most common measure of obesity be noted that BMI does not distinguish body is the body mass index (BMI), calculated as a fat from bone and muscle mass, leading some activities. Research further suggests person s weight in kilograms divided by his or researchers to argue for alternate measures that the biological and behavioral her height in meters squared. The standard (Burkhauser and Cawley, 2008). 58 An Aging World: 2008 U.S. Census Bureau

70 Figure 5-6. Percent Overweight and Obese Among Men and Women Aged 50 and Over in Ten European Countries: 2004 Greece Austria Germany Italy Spain Netherlands France Sweden Switzerland Denmark Greece Spain Germany Italy Netherlands Austria Sweden Denmark France Switzerland Men Women traits of obesity are influenced by social networks and social ties (Christakis and Fowler, 2007). Overweight, BMI 1 25 to BMI is body mass index. Source: Andreyeva, Michaud, and van Soest, Figure 5-6 presents a snapshot of the proportions overweight and obese for people aged 50 and over in 2004 in ten Western European countries that participate in the Survey of Health, Ageing and Obese, BMI 1 > Retirement in Europe (SHARE). When the two measures are combined, 59 percent to 71 percent of men aged 50 and over are overweight or obese in each country. Women in all the countries are less likely than men to be overweight or obese, with a range of 41 percent to 67 percent. The highest combined levels for men and women are seen in Greece and Spain. While the combined levels for older women are lower than for older men, women tend to have higher levels of obesity. There has been considerable speculation about the social impact of rising levels of obesity. In terms of mortality, it has been suggested that current life expectancy in the United States would be higher if overweight individuals were instead at their ideal weight. Obesity s tendency to reduce longevity means that the steady rise in U.S. life expectancy over the last two centuries could soon cease (Olshansky et al., 2005). 7 An analysis of the United States and Mexico concludes that among people aged 60 and over, larger losses in life expectancy associated with excess body fat appear among older people in Mexico than in the United States (Monteverde et al., 2007). On the other hand, some would argue that there is no consensus about the long-term consequences of obesity for overall mortality (Kramarow et al., 2007; and Preston, 2005). There seems to be more agreement that rising levels of obesity among older people will impact health and health care expenditures, given studies that show that the obese are more likely than the nonobese to have and report certain chronic conditions and that the former have higher levels of health care spending (OECD, 2006c). 7 Factors other than obesity per se may also be at work. A study of mortality during the period in the United States found that a large waist circumference was associated with an approximately 25 percent increase in mortality, even after adjustment for BMI (Koster et al., 2008). U.S. Census Bureau An Aging World:

71 EARLY-LIFE COnDITIOnS AFFECT ADuLT HEALTH The last two decades have seen a growing body of research that examines adult health from a lifecourse perspective. This research increasingly suggests that many negative health conditions in adulthood stem from risks established early in life (Gluckman and Hanson, 2004; Crimmins, 2005; and Case and Paxson, 2008). Some (notably, Barker, 2001) argue that adult health has a fetal origin whereby nourishment in utero and during infancy has a direct bearing on the development of risk factors for adulthood diseases (especially CVDs). Early malnutrition in Latin America is highly correlated with self-reported diabetes, and the experience of rheumatic heart fever is a strong predictor of adult heart disease (Palloni et al., 2006). Childhood infections may have longterm effects on adult mortality, and slow growth and lack of emotional support in prenatal life and early childhood reduce physical, cognitive, and emotional functioning in later (Wilkinson and Marmot, 2003). Data on China s oldest old show that people who rarely or never suffered from serious childhood illnesses, or who received adequate medical care during sickness in childhood, had a greatly reduced risk of being cognitively impaired or ADL-impaired at ages 80 and over (Zeng, Gu, and Land, 2007). Demonstrating that childhood conditions affect adult development and health is complicated because separating cohort effects from period effects (e.g., changing living conditions) is empirically difficult given the temporal and data requirements. The improvements in life expectancy at birth described in Chapter 4 largely are period effects of public health and medical advances. One study Figure 5-7. Probability of Being Disabled at Ages 60 and Over Conditional on Early Childhood Health Conditions in Seven Latin American/Caribbean Cities 1 and in Puerto Rico: Circa Poor health conditions Cities Good health conditions Puerto Rico The seven cities include Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; and Sao Paulo, Brazil. Source: Estimated from Monteverde, Noronha, and Palloni, looked at reduced lifetime expo- exposure to infectious diseases, sure to infectious diseases and such as typhus, polio, malaria, other sources of inflammation in and tuberculosis. In Puerto Rico, a nation with excellent historical the probability of being disabled data Sweden and concluded among people growing up in poor that reductions in early morbidity conditions was 60 percent higher do have an impact on observed than among people with better increases in life expectancy (Finch childhood socioeconomic levels. and Crimmins, 2004). Looking The corresponding figure among crossnationally at data from two the urban centers was 22 percent surveys of older populations 1 in (Figure 5-7). Current research is 7 urban centers in Latin America extending the range of causal and the Caribbean and 1 in Puerto early-life conditions. Currie (2008) Rico researchers investigated the argues that parental socioeconomic risk of being disabled according to status affects child health, which, conditions experienced early in life in turn, is related to future educa- (Monteverde, Noronha, and Palloni, tional and labor market outcomes. 2007). The birth and development A study in Denmark found that of today s older cohorts occurred mortality rates in later life were during times characterized by influenced by features of the macgenerally poor nutrition and roenvironment around the time of 60 An Aging World: 2008 U.S. Census Bureau

72 Figure 5-8. Health Expenditure and Percent Aged 65 and Over in 24 OECD Nations: 2003 Total expenditure on health as a percent of gross domestic product (GDP) United States 12 R squared = Japan 6 Turkey South Korea Percent aged 65 and over Sources: Organisation for Economic Co-Operation and Development (OECD), 2006d; and U.S. Census Bureau, International Data Base, accessed on September 10, birth, such as the business cycle, attributed to people aged 65 and fairly weak (Figure 5-8). A growfood price deviations, and weather over ranged from 32 percent to ing number of analyses suggest (van den Berg, Doblhammer-Reiter, 42 percent, compared with their that population aging is not the and Christensen, 2008). population share of 12 percent main driver of health care costs. to 18 percent (OECD, 1997). Per Other factors rising per capita DOES POPuLATIOn AGInG capita public health expenditures incomes, health insurance cover- IMPACT HEALTH SYSTEM for older people are higher than for age, new medical technology, SOLvEnCY? younger people; in OECD countries, and workforce demographics Population aging might be there is about a four-fold differ- that affect the unit cost of health expected to increase overall health ence between the 65-and-over and care may be more important care costs because health expendi- the under-65 aggregates (OECD, (Reinhardt, 2003; Zweifel, Felder, tures by and for older age groups 2006c). However, per capita expen- and Werblow, 2004; and Bryant tend to be proportionally higher ditures often level off or decline at and Sonerson, 2006). One analysis than their population share. This ages above 80. There also are con- of 21 OECD countries (White, 2007) could apply especially in nations siderable per capita differences by breaks down the temporal trend where acute care and institutional country, which may be attributed in health spending per capita into (long-term care) services are to variations in program coverage. three components: real growth widely available. A nine-country in gross domestic product (GDP) While health expenditures and study in the 1990s found that the per capita, changes in population population aging are related in share of total health expenditure aging, and an excess growth OECD nations, the relationship is U.S. Census Bureau An Aging World:

73 Figure 5-9. Components of Real Growth in Health Care Spending per Capita, United States and 20-Nation OECD Aggregate: 1970 to 2002 (Average annual percent change) OECD 1 Excess growth in health care spending Population aging Real growth in GDP United States 1 Organisation for Economic Co-Operation and Development (OECD). Note: The rate of excess growth is calculated as the rate of health spending per capita minus the rate of real growth in gross domestic product (GDP) per capita minus the rate of population aging. Source: White, category above and beyond the stemmed from real growth in GDP, increase attributable to economic while the effect of population aging growth and population aging. Over was smaller. The major difference the period , real growth between the United States and in per capita health care spending the OECD aggregate is the rate of averaged 4.3 percent in the United excess growth, calculated as the States and 3.7 percent in the other rate of health spending per capita OECD countries (Figure 5-9). About minus the rate of real growth in 2 percentage points of the growth GDP per capita minus the rate of population aging. Excess growth likely is related to the diffusion of new health care technologies and institutional features of the health care financing and delivery system (Jenson, 2007). Part of the debate over rising health care costs focuses on the distribution of expenditures by age. A large fraction of health care costs associated with advancing age are incurred in the year or just prior to death (Lee, 2007; and Shugarman et al., 2004). As more people survive to increasingly older age, the high cost of dying is shifted to ever-older ages, which, in theory, means that most agespecific costs may decline (Bolnick, 2004). One contentious issue in many societies relates to the nature and extent of treatment at very old ages. In a review of primarily U.S. data, the International Longevity Center reports no evidence that aggressive care at the end of life is increasing nor any indication that the cost of dying is growing and will overwhelm the health care system (Pan, Chai, and Farber, 2007). At the same time, governments and international organizations are stressing the need for cost-of-illness studies on age-related diseases, in part to anticipate the likely burden of increasingly prevalent and expensive chronic conditions (of which Alzheimer s disease may be the most costly). 62 An Aging World: 2008 U.S. Census Bureau

74 Box 5-3. Middle-Aged Britons Are notably Healthier Than Middle-Aged Americans Crossnational research using ongoing longitudinal studies in England and the United States has revealed that White non-hispanic middleaged Americans (aged 55 to 64) are not as healthy as their English counterparts, and in both countries, lower income and education levels are associated with poorer health. Comparable representative samples of people aged 55 to 64 from the U.S. Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) were divided into three socioeconomic groups based on education and income. The samples were limited to White non-hispanic populations, allowing researchers to control for special issues in different racial or ethnic communities in both countries. The healthiest Americans in the study, those in the highest income and education levels, had rates of diabetes and heart disease similar to the least healthy people in England, those in the lowest income and education levels (Banks et al., 2006). In addition, the lowest income and education group in each country reported the most cases of diabetes, stroke, heart disease and heart attacks, and chronic lung disease, while the highest income and education groups reported the least. The only disease for which this inverse relationship was not true was cancer. Differences between the two countries in smoking, obesity, and alcohol use explained little of the difference. The researchers noted that the health status differences between the United States and England existed despite greater U.S. health care expenditures and similar patterns in life expectancy between the two countries. A further study of U.S. health care expenditure levels exploited data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and the HRS, in addition to other survey and secondary information (Thorpe, Howard, and Galactionova, 2007). Results for 2004 suggested that disease prevalence and rates of medication treatment for people over the age of 50 were much higher in the United States than in ten European countries. The researchers noted that part of the difference may be related to a greater likelihood of diagnosis and treatment in the United States. For instance, the higher diagnosis rate for cancer in the United States appears to be a result of more intensive screening. However, higher rates of obesity-related diseases and conditions (e.g., high blood pressure) suggest that older Americans are less healthy than their European counterparts. U.S. Census Bureau An Aging World:

75 ChApTer 6. Gender Balance, Marital Status, and Living Arrangements One common characteristic of a sex ratio below 100 at ages 65 suicides, and other causes populations throughout the world and over. This is primarily the (Brainerd, 2001; Mesle and Vallin, is the preponderance of women at result of higher male than female 2002; and Varnik et al., 2001). older ages. Globally in 2008, there mortality rates beginning at birth In the future, many countries with are an estimated 62 million more and continuing throughout the life currently low sex ratios are prowomen than men aged 65 and course, which leaves fewer men jected to see an increase because over. Women are the majority of than women at older ages. adult male mortality rates are the older population in the major- Fewer than two dozen countries expected to improve faster than ity of countries, and their share of have a sex ratio higher than 100 those of women. 1 All Eastern the population increases with age. at older ages in At the other European and former Soviet This gender imbalance at older end of the spectrum are the very Union countries, for example, are ages has many implications for low sex ratios found in parts of the expected to experience an increase population and individual aging, former Soviet Union and Eastern in this indicator between 2008 and perhaps the most important of Europe. As of 2008, the world s The projected trend in aggrewhich involves marital status and lowest national sex ratio for the gate sex ratios for developed counliving arrangements. older population is 45 in Russia. tries is shown in Figure 6-2, with OLDER POPuLATIOn SEx Several other former Soviet repub- ratios increasing for ages 65 to 79 RATIOS very LOW In lics (e.g., Belarus, Latvia, and and 80 and over. The picture for EASTERn EuROPE Estonia) also have low sex ratios, developing countries is different. In as do several countries in South the aggregate, projections suggest The sex ratio, defined as the America and parts of Africa (Figure that there will be no appreciable number of men per 100 women, 6-1). The very low sex ratios in difference between 2008 and 2040 is a common measure of a popula- Eastern Europe derive partly from at ages 65 to 79 and a decline in tion s gender composition. Ratios the lingering effects of heavy male the sex ratio at ages 80 and over. over 100 indicate more men than mortality during World War II but women, and ratios under 100 more importantly stem from higher 1 indicate the opposite. The major- Sex ratios for four age groups in 2000, adult male than female mortality 2020, and 2040 for the 52 study countries ity of the world s countries have due to cardiovascular diseases, are presented in Appendix Table B-4. U.S. Census Bureau An Aging World:

76 66 An Aging World: 2008 U.S. Census Bureau Sex ratio Less than to to or more Figure 6-1. Sex Ratio of the Older Population: 2008 (Men aged 65 and over per 100 women aged 65 and over) Source: U.S. Census Bureau, International Data Base, accessed on May 27, 2008.

77 Figure 6-2. Aggregate Sex Ratios for Older Age Groups: 2008 and Developed countries Developing countries 80+ Source: U.S. Census Bureau, International Data Base, accessed on May 20, OLDER MEn ARE MARRIED; (Valkonen, Martikainen, and Widowhood has been associated OLDER WOMEn ARE Blomgren, 2004; and Murphy, with negative psychological well- WIDOWED Grundy, and Kalogirou, 2007). being of older people, with studies showing that the widowed are Extensive research has demon- Older men are more likely to be more likely than other groups to strated that being married benefits married than older women. The be depressed and unhappy about older people s mental health and latest available data on marital stalife and to suffer from loneliness other health outcomes. Studies in tus for the study countries in this and boredom (Delbes and Gaymu, Europe and the United States have report show that about 60 percent 2002; and Thierry, 2000). Data shown that married older people to 85 percent of men aged 65 and on widowhood in the study coungenerally are less likely to report over were married (Appendix Table tries with available information depressive symptoms and are more B-6). Even at ages 75 and over, 70 show that while 20 percent or less likely to report satisfaction with percent of men in a majority of the of older men were widowed, the life than their unmarried coun- study countries were married. In proportion widowed among older terparts, and that men appear to contrast, 30 percent to 40 percent women generally was in the 40 benefit from marriage more than of women aged 65 and over were percent range. More than half of all women (Brown, Bulanda, and Lee, married (with the exception of Sri older women in Eastern European 2005; Chipperfield and Havens, Lanka, where the proportion was countries were widows, as was the 2001; and Hagedoorn et al., 2006). 57 percent in 2001). At ages 75 case in most Asian and some Latin Multicountry studies also show and over, on average, 20 percent of American study countries. that married older people gener- women were married. This pattern ally have lower mortality rates is found in developed and developthan their nonmarried counterparts ing countries alike (Figure 6-3). U.S. Census Bureau An Aging World:

78 Figure 6-3. Percent Married at Older Ages for Selected Countries by Sex: Circa 2001 Developed countries Developing countries Male Female Greece, 2001 Argentina, to to and over and over and over and over New Zealand, 2001 Botswana, to to and over and over and over and over to 64 Russia, to 64 India, and over and over and over and over Sweden, 2001 Mexico, to to and over and over and over and over United States, 2006 Sri Lanka, to to and over and over and over and over Sources: Appendix Table B-6 and United Nations Department of Economic and Social Affairs, Demographic Yearbook 2006 (Special Census Topic). 68 An Aging World: 2008 U.S. Census Bureau

79 Figure 6-4. Percent Widowed in Denmark by Age and Sex: Percent 80 Female 60 Male Age Source: Statistics Denmark, WIDOWHOOD RISES the sex difference in life expec- study in four developed countries SHARPLY AFTER AGE 65 tancy, increases the chance that (United States, Germany, Great a woman will be widowed in her Britain, and Canada) found that Data from Denmark in 2007 older age. Furthermore, older wid- women in low-income households (Figure 6-4) display the typical owed men have higher remarriage were protected in all four countries upward curve of widowhood with rates than older widowed women by government programs that, on age, as well as gender differences. in many countries, often as a func- average, increased their household Widowhood for men is minimal tion of cultural norms. The fact that size-adjusted income following until age 50 and increases steeply women are likely to outlive their their husbands deaths. In contrast, from age 70 (11 percent) to age 90 spouse has important economic substantial declines in household (53 percent). Widowhood among consequences for individuals and size-adjusted income were more women increases noticeably at an societies. A comparison of longi- likely to be seen for women who earlier age (10 percent by age 60) tudinal data from Germany and lived in higher-income households and rises steeply after age 65. the United States revealed that prior to the deaths of their hus- The gender difference in marital although the level of poverty is bands (Burkhauser et al., 2005). status results from a combination different in the two countries, most Trend data from Appendix Table B-6 of factors. The first is the sex dif- women in both nations experisuggest that the gender gap in proference in longevity described in enced a decline in living standards portions married among older people Chapter 4 women on average live upon widowhood and many fell may be narrowing. Projections of longer than men. Secondly, women into poverty as a result of the loss marital status in the United Kingdom tend to marry men older than of public or private pension supindicate that the married proportion themselves which, combined with port (Hungerford, 2001). Another U.S. Census Bureau An Aging World:

80 Figure 6-5. Change in Proportions Married and Widowed for People Aged 65 and Over in the United Kingdom by Sex: 1971 to Percent 80 Male, married 60 Female, widowed 40 Female, married 20 Male, widowed Source: United Kingdom Office for National Statistics, of older men will decline from 2001 to 35 percent in These married, from southern and eastern 2001 to 2021, after being largely changes are partly due to the nar- regions in which marriage was earlier unchanged from 1971 to 2001 rowing of gender differentials in and more universal (Hajnal, 1965). (United Kingdom Office for National mortality discussed in Chapter 4, but Data from the late 1980s provide Statistics, 2004). The percent married they also reflect differences between one illustration of this difference 2 among older women increased dur- generations in the propensity to percent of older men in Bulgaria ing the period, and the marry earlier in life. Important differ- had never married, compared with projected gender gap of 21 percent- ences are also seen crossnationally. about 25 percent in Ireland (Grundy, age points in 2021 is a reduction In the1960s, research identified what 1996). The legacy of this difference from 38 percentage points in 1971 became known as the Hajnal Line, persisted throughout the twentieth (Figure 6-5). While a woman s likeli- distinguishing northern and western century and is still evident in the hood of being widowed was stable parts of Europe, which historically marital status distributions of today s from 1971 to 2001, the projected had late ages of marriage and rela- older populations. rate declines from 47 percent in tively large proportions who never 70 An Aging World: 2008 U.S. Census Bureau

81 Figure 6-6. Living Arrangements for Household Population Aged 65 and Over in Argentina: 2001 Nonfamily 0.9% With extended family 34.9% Alone 19.6% With spouse only 28.2% With spouse and children 16.4% Note: Excludes older people living in institutions (about 2.8 percent of the total population aged 65 and over). Source: Argentina National Institute of Statistics and Censuses, 2001 census data. MOST OLDER PEOPLE alone, while living with kin is still people benefit from extended RESIDE WITH FAMILY the norm in the developing world. family integration and experience Census data for Argentina favorable psychological outcomes The living arrangements of older (Figure 6-6) show that more than (Silverstein, Cong, and Li, 2006). people affect their life satisfaction, half of all noninstitutionalized older Studies throughout the developing health, and chances of institutionpeople lived with their children world have consistently shown the alization. Marital status, availability and/or their extended family in predominance of older people s of kin, personal wealth, health, More than one-fourth lived residence with adult children and/ and individual preferences are key with their spouse only, while or grandchildren, and that older determinants of an older person s one-fifth lived alone. The lat- people rely heavily on family memliving arrangements. Cultural ter two percentages are high by bers for their well-being and surnorms and social transfers of time, developing-country standards. In vival (Bongaarts and Zimmer, 2002; space, and money are equally important in deciding whether an Indonesia, Singapore, and Taiwan, and Zeng and George, 2000). older person lives alone or with most older people share a resi- In addition to norms that place family members. dence with kin and maintain such the responsibility for taking living arrangements for many care of older people on their Crossnational comparisons of older (Frankenberg, Chan, and Ofstedal, children, another reason for the people s living arrangements reveal 2002). In Bangladesh, more than prevalence of multigenerational substantial differences between 80 percent of older parents live coresidence in many developdeveloped and developing regions. with one or more children (Ghuman ing nations is that social transfer A major difference is that older and Ofstedal, 2004). In rural China, programs that enhance old-age people (especially older women) where multigenerational housesecurity and enable alternate in developed countries often live holds are nearly universal, older U.S. Census Bureau An Aging World:

82 Figure 6-7. Living Arrangements for People Aged 65 and Over in Japan: 1960 to 2010 (In percent) In institutions Alone With spouse only With married child(ren) Percentages living with married child(ren) include small numbers of older people living in unspecified arrangements. Source: Japan National Institute of Population and Social Security Research. living arrangements are lacking or InTERGEnERATIOnAL almost doubled (10 percent to 19 just beginning. In contrast, most CORESIDEnCE IS On percent) during the 25-year period industrialized countries have well- THE DECLInE (Karagiannaki, 2005). developed social transfer systems Although multigenerational fam- The decline of intergenerational (Palloni, 2001). Nevertheless, ily households, referred to here as coresidence has also occurred in multigenerational living arrange- coresidence, are still common, Japan, where the extended family ments remain common in some trend data show that multigenera- structure has historically been a Western countries. A study of tional living arrangements have prominent feature of society. During the older population in Spain, for been declining in many countries, the period, the proporexample, found that 66 percent of particularly in Europe. Over a tion of older Japanese living with those widowed and 34 percent of 25-year period (1974 to 1999) in children dropped from 87 percent those married lived with at least Greece, the proportion of unmar- to 56 percent, and it is projected one child (Zunzunegui, Beland, and ried older people living with a mar- to decline further to 42 percent by Otero, 2001). In addition, many ried child dropped from 23 percent At the same time, rising life older people not residing with their to less than 9 percent, and the expectancy has led to an increase children lived in the same neigh- proportion of older couples resid- in the joint survival of husbands borhood as their children. ing with a married child declined and wives to ever-older age, and from 14 percent to 5 percent. the share of older Japanese living While coresidence of older people with their spouse only has risen and their single children remained accordingly (Figure 6-7). Research stable over time, the share of on changing living arrangements unmarried older people living alone 72 An Aging World: 2008 U.S. Census Bureau

83 Figure 6-8. People Aged 65 and Over Living Alone in Ten European Nations by Sex: 2001 (In percent) Male Female Denmark Slovakia Germany Czech Republic Netherlands Switzerland Italy Poland Latvia Portugal Source: Ireland Central Statistics Office, in Japan points to a shift from a was the increasing resources of arrangements of older people in traditional preventive approach of the older people that facilitated Taiwan from 1989 to 2003 showed advance preparation for the age- independent living, while others substantial fluctuations in their related needs of older parents to found that the primary cause was coresidence status (Hermalin et a contingent approach of waiting increasing opportunities for the al., 2005). The study also found until older parents have specific young combined with declining that many of the socioeconomic needs (Takagi, Silverstein, and parental control over their children factors that predict coresidence Crimmins, 2007). There is evidence (Engelhardt, Gruber, and Perry, status at a single point of time did that older parents who begin living 2005; McGarry and Schoeni, 2000; not explain transitions in living with an adult child relatively late in and Ruggles, 2007). Researchers arrangements, and the authors the child s life are more likely than also caution against using data at suggested that future research on other parents to be widowed and/ a given point in time or on aggre- the determinants of transitions or in poor health. gate trends over time as preva- should incorporate changes in life lence measures because these course events, such as the health When studying the decline in the measures do not capture individ- and resources of the older people trend of intergenerational coresiual-level transitions in coresidence as well as opportunities and condence, some researchers hold of adult children and parents. straints for their children. that the main contributing factor Longitudinal data on the living U.S. Census Bureau An Aging World:

84 Figure 6-9. Living Arrangements for People Aged 60 and Over in Sub-Saharan Africa by Residence: Circa 2003 (In percent) Alone With at least one child With at least one grandchild In skipped-generation households Total Men, rural Men, urban Women, rural Women, urban 1 A skipped-generation household consists of at least one grandchild but no own children. Categories are not mutually exclusive or exhaustive. Source: Zimmer, nearly HALF OF OLDER in Bulgaria, the Czech Republic, and/or a reduction in social activ- WOMEn LIvE ALOnE In Estonia, Finland, and Romania (De ity (Dykstra, van Tilburg, and SOME EuROPEAn nations Vos and Sandefur, 2002). It is still Gierveld, 2005; and Jylha, 2004). relatively uncommon for older Researchers caution that living As older people become less likely people in developing countries to with others does not preclude to reside with their adult chillive alone (Table 6-1). loneliness, and that a spouse or dren, their proportion living alone children do not necessarily provide increases, especially in developed A large amount of research has stronger emotional companioncountries (Grundy, 2001). The sought to understand the relaship than friends. A longitudinal phenomenon of older people liv- tionship between living alone study of female nurses aged 60 to ing alone is particularly salient in and loneliness. The consensus is 72 in the United States found that, European Union member states that living alone does not equate compared with those living with (Figure 6-8). Around half of women to loneliness, although the two their spouse, women living alone aged 65 and over in Denmark, may be related. Loneliness can be were not more socially isolated Slovakia, and Germany lived alone emotional (the lack of a specific, and had better measures of cogniin Because older men are intimate relationship) or social tive health (Michael et al., 2001). less likely than older women to be (the lack of social integration and Data from the English Longitudinal widowed, they are also less likely embeddedness) (van Tilburg, Study of Aging (Demakakos, Nunn, to live alone. In the ten European Havens, and Gierveld, 2004). In the and Nazroo, 2006) indicate that Union countries in Figure 6-8, the European context, research sugolder people who had children but percentage of older men living gests that loneliness increases with did not feel close to any of them alone ranged from 10 percent to age but may not be due to aging were more likely to feel lonely than 26 percent. That older women are per se. Rather, loneliness could be people without children. more likely to live alone than older the result of weakened social intemen also has been documented gration due to increasing disability 74 An Aging World: 2008 U.S. Census Bureau

85 Table 6-1. Percent of People Aged 60 and Over Living Alone by Sex: Circa 2000 SkIPPED-GEnERATIOn HOuSEHOLDS ARE A FEATuRE OF SuB-SAHARAn AFRICA Country Survey year Male Female Africa Benin Egypt Ethiopia Gabon Malawi Mali Rwanda Zambia / Asia Armenia Bangladesh / India / Nepal Philippines Turkey Latin America/Caribbean Colombia Dominican Republic Guatemala / Haiti Mexico Panama Peru Source: United Nations, Department of Economic and Social Affairs, Sub-Saharan Africa is the region most seriously affected by HIV/ The impact of the worldwide HIV/ AIDS pandemic on older people has become the focus of a growing body of research (e.g., Knodel and Saengtienchai 2005; Zimmer and Dayton, 2003; and Knodel et al., 2007). The pandemic affects HIV/ AIDS parents (i.e., older parents of adult children who die of AIDS) in multiple ways, including caregiv- ing, coresidence, providing material support, fostering grandchildren, loss of children, and the communi- ty s reaction (Knodel, Watkins, and VanLandingham, 2002). AIDS. The Joint United Nations Programme on HIV/AIDS estimated that 29.4 million of the 33.2 million people worldwide living with HIV/ AIDS in 2007 lived in Sub-Saharan Africa (UNAIDS and World Health Organization, 2007). A study of 22 countries in the region, based on data from the Demographic and Health Survey program, examined variations in living arrangements of older people as well as changes over time (Zimmer, 2007). Of particular interest to this chapter is the skipped-generation household structure, where an older person or couple resides with at least one grandchild without the presence of middle-generation family members. Overall, about 14 percent of older people lived in a skipped-generation household in the early-to-mid 2000s (Figure 6-9). Rural older people were more likely than their urban counterparts, and women were more likely than men, to live in a skippedgeneration household. The skipped-generation family structure is not new in Africa, as rural young adults have frequently migrated to urban areas for job opportunities and left young children behind in the care of their grandparents. Today, however, middle-generation adults are increasingly infected with HIV and die of AIDS, and thus the skippedgeneration household increasingly consists of the parents of people with HIV/AIDS and their grandchildren. When they are the only adults in the household, older people shoulder the financial and emotional responsibility of raising their grandchildren, often with meager resources (Ferreira, 2004). Table 6-2 indicates the association between HIV/AIDS deaths and the skipped-generation household living arrangement. Older people living in countries with higher cumulative crude death rates due to HIV/AIDS generally are more likely to live in a skipped-generation household or a household where the resident grandchildren have lost both parents (such children are sometimes called double orphans). The 22-nation study also found that over the period of a decade, the increase in the proportion of older adults living with their double-orphaned grandchild was higher in countries that have higher HIV/AIDS prevalence. The patterns confirm that HIV/AIDS deaths often require grandparents to care for their orphaned grandchildren. U.S. Census Bureau An Aging World:

86 Table 6-2. Cumulative Crude Death Rate Due to AIDS and Living Arrangements of People Aged 60 and Over in 22 Sub-Saharan African Countries: Circa 2003 Country Year of DHS survey Cumulative crude death rate 1 Percent living in a skippedgeneration household Percent living in a double-orphaned household Madagascar Senegal Benin Mali Guinea Gabon Nigeria Ghana Chad Namibia Cameroon Ethiopia Burkina Faso Rwanda Mozambique Congo Kenya Tanzania Malawi Lesotho Uganda Zambia Cumulative crude death rates are estimates of the total number of deaths ever occurring inacountry due toaids expressed per 1,000 individuals living in the country in the year of the Demographic and Health Survey (DHS). Source: Zimmer, use OF LOnG-TERM CARE and the economic resources of older of older people with dementia or FACILITIES varies BY people and their adult children. A Alzheimer s disease (Hebert et al., SOCIAL GROuP longitudinal study in England and 2001; and Soto et al., 2006). Wales linked records of the surviv- Although there is no universal defi- Institutional residence has become ing sample of community-dwelling nition, long-term care facilities usu- an option for older people in develpeople aged 65 and over in 1991 ally include nursing homes, assisted oped countries who have difficulwho had moved into institutional living/residential care facilities, and ties with activities of daily living care by 2001 (Grundy and Jitlal, sometimes hospice centers. The or who require specialized medical 2007). The results showed that need for long-term care usually is services. Some nations have uniolder age, living in rented housmost acute and most concentrated versal systems of long-term care ing, living alone in 1991 and being during the period of frailty associ- for their older populations (and unmarried in 2001, and long-term ated with advanced old age (Leung, for younger people with disabiliillness were the main sociodemo- 2000). Women and the oldest old ties), and Japan requires mandagraphic factors contributing to are likely to be overrepresented tory long-term care insurance institutionalization. Among women, among long-term care residents. (International Longevity Center, being childless also was a factor. Residential aged-care data from 2006; and Lundsgaard, 2005). The Similar findings were reported by an Australia show that in 2007, 71 highest rates of institutional use earlier study in the United Kingdom percent of all such residents were are seen in some of the world s (Hancock et al., 2002). Studies women and 54 percent were aged demographically oldest countries. in Canada and France also found 85 and over (Australian Institute Crossnational comparisons of caregiver burden (a term used to of Health and Welfare, 2008). institutionalized populations are describe the physical, emotional, Institutional use is also associated problematic due to the absence of and financial toll of providing care) with marital status, prior living internationally consistent data, but to be an independent factor associarrangements, older people s health, one attempt to collate reasonably ated with the institutionalization 76 An Aging World: 2008 U.S. Census Bureau

87 Figure Percentage of People Aged 65 and Over in Institutions: Circa 2001 Norway, Denmark, Netherlands, Sweden, France, 1997 Belgium, 1998 Japan, Australia, 2003 Finland, United Kingdom, 1996 Austria, 1998 Israel, 2000 United States, Germany, Netherlands and the Nordic countries include people in service housing. 2 Japan includes people in long-stay hospitals. Source: Gibson, Gregory, and Pandya, comparative data on institutional of users back into the community, and anticipated problems (United living showed that the percentage while other systems have relatively Nations Department of Economic of older people living in institutions limited rehabilitative services. and Social Affairs, 2007a). Longin developed countries around the term care provision and/or homes Rates of institutionalization usuyear 2001 ranged from 4 percent for the aged have become increasally are low or negligible in the to 12 percent (Figure 6-10). More ingly accepted and common in developing world (United Nations than 8 percent of people aged 65 countries especially in Southeast Department of Economic and Social and over in Norway, Denmark, the Asia where sustained fertility Affairs, 2005), where social tradi- Netherlands, and Sweden were in declines have led to rapid populations and official decrees of filial various types of long-term care tion aging and reduced the number and familial responsibility have facilities. People in institutions at of potential family caregivers. A discouraged debate about living one point in time do not neces- number of researchers and mediarrangements of older people. sarily remain there and age in cal practitioners (e.g., Chiu and Lately, however, a number of counplace indefinitely. Many older Chiu, 2005; Mangone and Arizaga, tries have recognized that even if individuals who enter an institu- 1999; and Phillips and Chan, 2002) the family retains much of the suption eventually leave, and many have raised warnings about the port function for older members, make multiple transitions. Some increasing prevalence of dementia demographic and socioeconomic national nursing home systems in developing countries and the changes are straining this arrange- (e.g., the Netherlands) have well- attendant implications for longment. Consequently, many develdeveloped rehabilitative programs term care. oping nations have adopted new that discharge a high proportion policies aimed at alleviating current U.S. Census Bureau An Aging World:

88 ChApTer 7. Social and Family Support Population aging puts pressure on SOME COunTRIES HAvE over tend to have the highest ODRs a society s ability to support its JuST THREE WORkInG- (Figure 7-1). Among the 52 study older members, who may com- AGED PEOPLE PER OnE countries in this report, the ODR in pete with the young for resources, OLDER PERSOn 2008 ranged from 6 in Kenya and especially when the ratio between Uganda to 36 in Japan. Japan s ODR A commonly used indicator of the working-aged population and of 36 means that fewer than three societal support is a dependency the older population becomes low. working-aged people aged 20 to ratio, the ratio between youth and/ The statistics discussed in the first 64 supported one older person in or older people and working-aged part of this chapter may be seen as Figure 7-2 presents a global people. Herein, the older depenbroad indicators of how changing view of older dependency ratios dency ratio (ODR) is defined as the national age distributions could in The highest ODRs are number of people aged 65 and over affect the need for social services, seen in Western and some Eastern per 100 people aged 20 to 64. Not housing, and consumer products European countries and Japan. surprisingly, countries with high for older people. In contrast, the ODR is less than percentages of people aged 65 and Figure 7-1. Older Dependency Ratio for 20 Countries: 2008 (People aged 65 and over per 100 people aged 20 to 64) Japan 36 Italy 33 Greece Belgium France 28 Latvia 27 United Kingdom Ukraine Belarus Russia 22 United States Argentina Israel South Korea China Brazil 11 South Africa 10 Egypt Bangladesh 7 9 Kenya 6 Source: U.S. Census Bureau, International Data Base, accessed on January 10, U.S. Census Bureau An Aging World:

89 80 An Aging World: 2008 U.S. Census Bureau Older dependency ratio Less than to to or more Figure 7-2. Older Dependency Ratio: 2008 Note: Older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to 64. Source: U.S. Census Bureau, International Data Base, accessed on May 27, 2008.

90 Figure 7-3. Older Dependency Ratio for World Regions: 2000, 2020, and Northern Africa Sub-Saharan Africa Asia (excluding Near East) Near East Eastern Europe Western Europe Latin America/ Caribbean Northern America Oceania Note: Older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to 64. Source: U.S. Census Bureau, International Data Base, accessed on January 10, Table 7-1. Total, Older, and Youth Dependency Ratios for World Regions: 2008 Region Total dependency ratio 1 Older dependency ratio Youth dependency ratio Northern Africa Sub-Saharan Africa Asia (excluding Near East) Near East Eastern Europe Western Europe Latin America/Caribbean Northern America Oceania The total dependency ratio is the number of people aged 0to19 and 65 and over per 100 people aged 20 to 64. It is composed of the older dependency ratio, which is the number of people aged 65 and over per 100 people aged 20 to 64, and the youth dependency ratio, which is the number of people aged 0to19 per 100 people aged 20 to 64. Figures may not sum to totals due to rounding. Source: U.S. Census Bureau, International Data Base, accessed on January 10, in a large majority of countries in Africa and southern Asia. Projections suggest that the ODR for Europe as a whole will double from 24 in 2000 to 48 by 2040, implying that the ratio of workers to older people could be only 2 to 1 in three decades time. At the other end of the spectrum, the predicted relatively high fertility, coupled with the impact of HIV/AIDS, in Sub- Saharan Africa will likely preclude a major change in the regional ODR (Figure 7-3). U.S. Census Bureau An Aging World:

91 Box 7-1. Standard and Alternative Older Dependency Ratios as defined above. The second, third, and fourth bars represent alternative older dependency ratios. The second bar includes only the economically active population aged 20 to 64 in the denomina- tor, excluding such categories as unpaid household workers, nonworking students, discouraged workers, and perhaps individuals whose health status keeps them out of the labor force. The third bar represents a calculation similar to the second bar but removes economically active people aged 65 and over from the numerator on the assumption that they are not economically dependent. The fourth bar builds on the third bar by adding these economically active older people to the ratio denominator of other eco- nomically active individuals on the assumption that these working older people contribute tax revenue to national coffers. By taking into consideration the status of economic activity, alternative dependency ratios may provide a clearer picture of a society s support burden. The alternative ratios in each country are higher than the standard ratio, even when the calculations Implicit in the standard definition of an older dependency ratio is the notion that all people over age 64 are no longer working and, in some sense, are dependent on the population in the working ages (20 to 64 ) who provide indirect support to older people through taxes and contributions to social welfare programs. However, not all older people require support, and not all working-aged people actually work or provide direct support to older family members. Older populations are diverse in terms of resources, needs, and abilities. Older people pay taxes and often have income and wealth that fuel economic growth. As discussed in Chapter 9, labor force participation rates at ages 65 and over have been increasing in many countries. While it is empirically difficult to include factors such as intrafamily financial assistance and child-care activities in an aggregate measure of social support, it is feasible to take account of employment charac- teristics in both the working-aged and older populations. In Figure 7-4, the left bar for each country corresponds to the standard older dependency ratio Figure 7-4. Standard and Alternative Older Dependency Ratios for Five Countries: 2006 Total population aged 65 and over per 100 total population aged 20 to 64 Total population aged 65 and over per 100 economically active population aged 20 to 64 Noneconomically active population aged 65 and over per 100 economically active population aged 20 to 64 Noneconomically active population aged 65 and over per 100 economically active population aged 20 and over Australia Canada Chile Poland South Korea Source: International Labour Organization, <http://laborsta.ilo.org>, accessed on February 6, An Aging World: 2008 U.S. Census Bureau

92 Box 7-1. Standard and Alternative Older Dependency Ratios Con. for factors such as workers under age 20, trends in unemployment, average retirement ages, levels of pension receipt and institutionalization among the older population, and the prevalence of high- cost disabilities. While standard older dependency ratios provide us with a rough idea of changing demographics, changes in government policies and people s behavior (e.g., propensities to save through- out a lifetime or to work at older ages) will affect the impact of demographic change. include noneconomically active older people in the numerator and economically active older people in the denominator (the fourth bar). The exception is South Korea, where older people have a relatively high rate of labor force participation. To the extent that policy and program agencies use dependency ratio calculations, the effect of including or excluding labor force participation rates appears considerable in most countries. Data permitting, other adjustments might be made to these ratios to account Figure 7-5. Composition of Total Dependency Ratios for Selected Countries: 2008 Older dependency ratio 1 Youth dependency ratio 2 Total dependency ratio 3 Burma Japan Cyprus Germany Brunei Italy Kuwait Bulgaria Older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to Youth dependency ratio is the number of people aged 0 to 19 per 100 people aged 20 to Total dependency ratio is the number of people aged 0 to 19 and 65 and over per 100 people aged 20 to 64. Youth and older ratios may not sum to total ratio due to rounding. Source: U.S. Census Bureau, International Data Base, accessed on February 6, ELEMEnTS OF THE TOTAL ratio (TDR) is an indicator of soci- in 2008, Sub-Saharan Africa stands DEPEnDEnCY RATIO ety s total support needs. The TDR out with a TDR of 131, indicating REFLECT AGE STRuCTuRE combines the ODR with a youth that the total of younger and older AnD SuPPORT needs dependency ratio (YDR), defined in people exceeded the number of this report as the number of people working-aged people (Table 7-1). Nonworking older people are not aged 0 to 19 per 100 people aged the only group a society s work- Eastern Europe had the lowest TDR 1 20 to 64. Looking at world regions ing population needs to support. A (57) among world regions in nation s young are the other half of 1 Older, youth, and total dependency ratios More than 40 percent of Eastern the equation. The total dependency in 2000, 2020, and 2040 are presented for the 52 study countries in Appendix Table B-7. Europe s dependency came from U.S. Census Bureau An Aging World:

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